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Transgender regret? Research challenges narratives about gender-affirming surgeries

Assistant Professor of Health, Behavior and Society, Johns Hopkins University

Postdoctoral Research Fellow in Plastic and Reconstructive Surgery, Johns Hopkins University

Assistant Professor of Plastic and Reconstructive Surgery, Johns Hopkins University

Disclosure statement

Harry Barbee has received funding from the National Institute on Aging for their past work.

Bashar Hassan and Fan Liang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

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You’ll often hear lawmakers , activists and pundits argue that many transgender people regret their decision to have gender-affirming surgeries – a belief that’s been fueling a wave of legislation that restricts access to gender-affirming health care.

Gender-affirming care can include surgical procedures such as facial reconstruction, chest or “top” surgery , and genital or “bottom” surgery .

But in an article we recently published in JAMA Surgery, we challenge the notion that transgender people often regret gender-affirming surgeries.

Evidence suggests that less than 1% of transgender people who undergo gender-affirming surgery report regret. That proportion is even more striking when compared to the fact that 14.4% of the broader population reports regret after similar surgeries.

For example, studies have found that between 5% and 14% of all women who receive mastectomies to reduce the risk of developing breast cancer say they regretted doing so. However, less than 1% of transgender men who receive the same procedure report regret.

These statistics are based on reviews of existing studies that investigated regret among 7,928 transgender individuals who received gender-affirming surgeries. Although some of this prior research has been criticized for overlooking the fact that regret can sometimes take years to develop, it aligns with the growing body of studies that show positive health outcomes among transgender people who receive gender-affirming care.

Why access to gender-affirming surgery matters

About 1.6 million people in the U.S. identify as transgender. While only about 25% of these individuals have obtained gender-affirming surgeries, these procedures have become more commonplace . From 2016 to 2020, roughly 48,000 trans people in the U.S. received gender-affirming surgeries.

These procedures provide transgender people with the opportunity to align their physical bodies with their gender identity, which could positively impact mental health. Research shows that access to gender-affirming surgeries may reduce levels of depression, anxiety and suicidal ideation among transgender people.

The mental health benefits may explain the low levels of regret. Transgender people have far higher rates of mental health concerns than cisgender people, or people whose gender identity aligns with their sex at birth. This is largely because transgender people have a more difficult time living authentically without experiencing discrimination, harassment and violence .

Gender-affirming surgery often involves going through a number of hoops : waiting periods, hormone therapy and learning about the potential risks and benefits of the procedures. Although most surgeries are reserved for adults, the leading guidelines recommend that patients be at least 15 years old.

This thorough process that trans people go through before receiving surgery may also explain the lower levels of regret.

In addition, many cisgender people get surgeries that, in their ideal world, they wouldn’t receive. But they go through with the surgery in order to prevent a health problem.

For instance, a cisgender woman who receives a mastectomy to avoid breast cancer may ultimately regret the decision if she dislikes her new appearance. Meanwhile, a transgender man who receives the same procedure is more likely to be pleased with a masculine-looking chest.

Improving research and public policy

It’s important to note that this research is not conclusive. Views of surgeries can change over time , and patients can feel quite differently about their outcomes eight years after their surgery as opposed to one year after their surgery.

Nonetheless, the consensus among experts, including at the American Medical Association , is that gender-affirming surgery can improve transgender people’s health and should not be banned.

U.S. states such as Oklahoma and North Dakota have ignored this consensus and have restricted access to these procedures. In response, 12 states have designated themselves “ sanctuaries ” for gender-affirming care.

Although our statistics on surgical regret may change as researchers learn more, they are the best data that health care providers have. And public policies that are based on the best available evidence have the most potential to improve people’s lives.

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Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Sasha karan narayan.

1 Department of Surgery, Oregon Health and Science University, Portland, OR, USA;

Rayisa Hontscharuk

2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA;

Sara Danker

3 Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA;

Jess Guerriero

4 Transgender Health Program, Oregon Health & Science University, Portland, OR, USA;

Angela Carter

5 Primary Care, Equi Institute, Portland, OR, USA;

Gaines Blasdel

6 NYU Langone Health, New York, NY, USA;

Rachel Bluebond-Langner

Randi ettner.

7 University of Minnesota, Minneapolis, MN, USA;

8 Callen-Lorde Community Health Center, New York, NY, USA;

Loren Schechter

9 The University of Illinois at Chicago, Chicago, IL, USA;

10 Rush University Medical Center, Chicago, IL, USA;

11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA;

Jens Urs Berli

12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA

Associated Data

The article’s supplementary files as

A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions

In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Introduction

Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.

The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:

• The current literature regarding the etiology of regret following gender-affirming surgery;
• The experience of surgeons regarding requests for surgical reversal.

Based on these results, the authors propose a classification system for both type and etiology of regret.

It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).

A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.

Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.

Statistical analysis

Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.

Narrative literature review

A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.

Ethical statement

This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Survey results

Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).

Distribution of transgender surgery experiences among respondents.

Number of transgender patients encountered who expressed regret.

Totals do not add to 100 due to incomplete responses.

Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .

Totals exceed 100 as respondents could select multiple options.

Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).

Respondent’s requirements to proceed with surgical reversal.

Literature review

Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.

Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.

Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).

Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).

Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.

While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).

As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.

Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.

Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.

Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).

Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.

True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.

Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.

Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.

Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.

Associated definitions

Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.

Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.

Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.

Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).

Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.

Special considerations

We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.

A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.

Limitations

The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.

Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.

Supplementary

Acknowledgments.

The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.

This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.

Funding : None.

Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.

Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204

Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204

Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.

FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

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How Often Do People Regret Transitioning?

It’s a complex question, but we do have some data..

An opinion piece recently came out in the New York Times looking at the ongoing debate on transgender youth. If you’ve read the piece, you might be forgiven for thinking that huge swaths of children are receiving surgery for gender dysphoria, and that many or even most of them regret their transitions. “I realized that I had lived a lie for over five years,” one destransitioning teen told the Times . Members of the trans community who track legislation and critique media coverage called the piece misleading , and even suggested it followed the “ climate denier playbook .”

Now, I have no particular stake here. I’m not trans, I don’t work in that area of health care, and I’m a cis man. I am, however, an epidemiologist, and I spend a lot of my time checking scientific facts that are online with the goal of helping people better understand health, science, and how the media covers those things. In this case, one key question arose from the New York Times piece that author Pamela Paul did not really answer: What proportion of people who access medical care to transition genders regret doing so?

You might answer, “Why does anyone care?,” which is, to be honest, not unreasonable . Some proportion of people experience regret for any medical procedure, from chemotherapy to orthopedic surgery. Nonetheless, we don’t see op-eds about the awful risks of hip replacements. It’s inevitable that some percentage of teens who transition will regret it; the real question is whether the medical care is beneficial on the whole—not whether the occasional person later regrets a medical choice they made in their youth.

It’s also important to note that we don’t really care about the crude number of people who regret transition, we care about the rate . If more people choose to transition, then more people, in total, will regret it. If the number of people transitioning goes from (to use arbitrary numbers) 1,000 to 100,000, but the number of people regretting it goes from 50 to 100, then the rate has dropped massively and it’s a very good thing, even though the crude number has doubled.

A good place to start when looking at the rate of regret for people transitioning in modern medical settings is to think about the upper and lower bounds. The highest estimate that I’ve come across is this recent study of people using the U.S. military health care system. It doesn’t deal with regret head-on, though. The authors looked at transgender or gender-diverse people who were using their parent’s or spouse’s military health care to access hormones for gender-related care, and looked at how many of them stopped getting these drugs over a four-year period. At the end of the study, about 30 percent of the people who started accessing hormones through this system stopped, with a lower rate for kids and higher rate for adults. (They may have gone elsewhere for hormones, though.)

The lowest estimate I’ve seen for regret after gender-related care is based primarily on people who have had gender-affirming surgery. A recent systematic review and meta-analysis —a type of study where the authors aggregate lots of papers into one big estimate—that combined such studies found an overall rate of 1 percent for regret after surgery for both transmasculine and transfeminine surgeries. This echoes other large cohorts which have found that only a tiny proportion of the people who have these surgeries eventually report regretting the procedure.

The issue here is that neither of these extremes are reliable estimates of regret. The 30 percent figure obviously does not map onto regret. Many people stop using their parent or partner’s health care for reasons completely unrelated to transition regret (i.e., divorce). And the studies of surgery in the review are mostly surgeons following up with their own patients, with quite high dropout rates. It’s not surprising that only 1 percent of people report to a surgeon who did an operation that they regret it!

There’s also a problem here about how we define “regret.” One of the biggest studies on transition-related regret was on the Amsterdam gender clinic , including nearly 7,000 people over 43 years. These authors defined “regret” as a patient who came back to the clinic after surgery to access hormones that would reverse their gender transition (and who had this noted in their records). By this definition, less than 1 percent of people regretted their surgery. But this is obviously not a particularly useful definition, because it will miss all of the people who regretted their procedures but went elsewhere for their follow-up care, or simply never got back to the original clinic about their regret.

Perhaps the most useful way to examine regret is to look at the proportion of people who cease their transition and go back to the gender they were originally. A large national study found that 13.1 percent of transgender people participating in the U.S. Transgender Survey reported detransitioning at some point in their lives. I think that’s a fairly reasonable estimate of the rate of people experiencing some measure of regret around their transition experience.

The authors of this study are careful to argue that the 13.1 percent figure isn’t a measure of regret, saying that “these experiences did not necessarily reflect regret regarding past gender affirmation.” Most of them reported that external factors were behind their detransition—a common reason was “pressure from a parent”—and all of them still identified as trans when they took part in the survey.

However, I think that the figure in that study is useful for precisely the reasons discussed in the study itself: Neither detransition nor regret are simple concepts. Transition, as with all social phenomena, is complex. You can stop taking hormones and still be trans. You can regret taking steps that alienate you from your family, even as you wish your family would accept you living how you want to live. You can even regret some aspects of a treatment (any kind of medical treatment!) while being grateful for the knowledge you gained by trying it out. Regret doesn’t always mean that people wish they hadn’t transitioned, it just means that there are some parts of the story that they long to change.

Paul published a short follow-up in the Times pushing back on criticisms of her column, arguing that we simply don’t know how many trans teens will seek medical care and then go on to detransition. It’s true that we don’t have good U.S. data on the number of people who detransition, but other countries have fairly useful, recent papers showing that detransition is quite uncommon . Paul even cited one of these in her piece, although she dismissed it out of hand . It’s possible that we don’t have all the information yet, but we can consider the constellation of evidence that we do have. What’s clear from this evidence is that the vast majority of people do not experience regret, howsoever defined, after transitioning genders. Regret rates are actually much higher for a lot of medical procedures. For example, in the U.S. military study above, 26 percent of children stopped getting hormones through their parent’s insurance after four years; a national British study looking at antidepressant use in children across the country found that half of the kids had stopped taking these medications after just two months.

Ultimately, the question of what proportion of kids or adults regret their transition is only important to a select group: the people who want to transition, and their clinicians. At worst, the rate of regret is still better than other treatments which don’t require national debates over their use, which really begs the question of why anyone who isn’t directly involved with the treatment of transgender people is even weighing in on the topic at all. Indeed, a lot of what I’ve said in this piece has been raised by everyone from journalists to activists to trans folks just trying to live their lives. But as long as columnists are asking questions, maybe I can help by offering answers.

A Reuters Special Report

Why detransitioners are crucial to the science of gender care.

UNDONE: Max Lazzara lived as a transgender man for eight years before detransitioning in 2020. She says she now realizes that gender-affirming medical treatment was not appropriate for her and that it took a toll on her physical and mental health. REUTERS/Matt Mills McKnight

USA-TRANSYOUTH/OUTCOMES

Understanding the reasons some transgender people quit treatment is key to improving it, especially for the rising number of minors seeking to medically transition, experts say. But for many researchers, detransitioning and regret have long been untouchable subjects.

By ROBIN RESPAUT , CHAD TERHUNE and MICHELLE CONLIN

Filed Dec. 22, 2022, noon GMT

For years, Dr Kinnon MacKinnon, like many people in the transgender community, considered the word “regret” to be taboo.

MacKinnon, a 37-year-old transgender man and assistant professor of social work at York University here, thought it was offensive to talk about people who transitioned, later regretted their decision, and detransitioned. They were too few in number, he figured, and any attention they got reinforced to the public the false impression that transgender people were incapable of making sound decisions about their treatment.

“This doesn’t even really happen,” MacKinnon recalled thinking as he listened to an academic presentation on detransitioners in 2017. “We’re not supposed to be talking about this.”

MacKinnon, whose academic career has focused on sexual and gender minority health, assumed that nearly everyone who detransitioned did so because they lacked family support or couldn’t bear the discrimination and hostility they encountered – nothing to do with their own regret. To learn more about this group for a new study, he started interviewing people.

In the past year, MacKinnon and his team of researchers have talked to 40 detransitioners in the United States, Canada and Europe, many of them having first received gender-affirming medical treatment in their 20s or younger. Their stories have upended his assumptions.

Many have said their gender identity remained fluid well after the start of treatment, and a third of them expressed regret about their decision to transition from the gender they were assigned at birth. Some said they avoided telling their doctors about detransitioning out of embarrassment or shame. Others said their doctors were ill-equipped to help them with the process. Most often, they talked about how transitioning did not address their mental health problems.

In his continuing search for detransitioners, MacKinnon spent hours scrolling through TikTok and sifting through online forums where people shared their experiences and found comfort from each other. These forays opened his eyes to the online abuse detransitioners receive – not just the usual anti-transgender attacks, but members of the transgender community telling them to “shut up” and even sending death threats.

“I can’t think of any other examples where you’re not allowed to speak about your own healthcare experiences if you didn’t have a good outcome,” MacKinnon told Reuters.

The stories he heard convinced him that doctors need to provide detransitioners the same supportive care they give to young people to transition, and that they need to inform their patients, especially minors, that detransitioning can occur because gender identity may change. A few months ago, he decided to organize a symposium to share his findings and new perspective with other researchers, clinicians, and patients and their families.

Not everyone was willing to join the discussion. A Canadian health provider said it couldn’t participate, citing recent threats to hospitals offering youth gender care. An LGBTQ advocacy group refused to promote the event. MacKinnon declined to identify either, telling Reuters he didn’t want to single them out. Later, after he shared his findings on Twitter, a transgender person denounced his work as “transphobia.”

He expected his research would be a hard sell even to many of the 100 or so people from Canada, the United States and elsewhere who accepted his invitation. “I need your help,” he told the crowd that assembled in November in a York University conference room for the daylong session. “My perspectives have changed significantly. But I recognize that for many of you, you may find yourselves feeling much like I did back in 2017 – challenged, apprehensive, maybe fearful.”

Fighting words

In the world of gender-affirming care, as well as in the broader transgender community, few words cause more discomfort and outright anger than “detransition” and “regret.” That’s particularly true among medical practitioners in the United States and other countries who provide treatment to rising numbers of minors seeking to transition.

They insist, as MacKinnon once did, that detransitioning is too rare to warrant much attention, citing their own experiences with patients and extant research to support their view. When someone does detransition, they say, it’s almost never because of regret, but rather, a response to the hardship of living in a society where transphobia still runs rampant.

“These patients are not returning in droves” to detransition, said Dr Marci Bowers, a transgender woman, gender surgeon and president of the World Professional Association for Transgender Health (WPATH), an international group that sets guidelines for transgender care. Patients with regret “are very rare,” she told Reuters. “Highest you’ll find is 1% or 1.5% of any kind of regret.”

Doctors and many transgender people say that focusing on isolated cases of detransitioning and regret endangers hard-won gains for broader recognition of transgender identity and a rapid increase in the availability of gender care that has helped thousands of minors. They argue that as youth gender care has become highly politicized in the United States and other countries, opponents of that care are able to weaponize rare cases of detransition in their efforts to limit or end it altogether, even though major medical groups deem it safe and potentially life-saving.

“Stories with people who have a lot of anger and regret” about transitioning are over-represented in the media, and they don’t reflect “what we are seeing in the clinics,” said Dr Jason Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital in Providence, Rhode Island. He also helped write the American Academy of Pediatrics’ policy statement in support of gender-affirming care. Detransitioning is a “very invalidating term for a lot of people who are trans and gender-diverse,” Rafferty said.

Some people do detransition, however, and some do so because of regret. The incidence of regret could be as low as clinicians like Bowers say, or it could be much higher. But as Reuters found, hard evidence on long-term outcomes for the rising numbers of people who received gender treatment as minors is very weak.

Dr Laura Edwards-Leeper, a clinical psychologist in Oregon who treats transgender youths and a co-author of WPATH’s new Standards of Care for adolescents and children, said MacKinnon’s work represents some of the most extensive research to date on the reasons for detransitioning and the obstacles patients face. She said the vitriol he has encountered illustrates one reason so few clinicians and researchers are willing to broach the subject.

“People are terrified to do this research,” she said.

For this article, Reuters spoke to 17 people who began medical transition as minors and said they now regretted some or all of their transition. Many said they realized only after transitioning that they were homosexual, or they always knew they were lesbian or gay but felt, as adolescents, that it was safer or more desirable to transition to a gender that made them heterosexual. Others said sexual abuse or assault made them want to leave the gender associated with that trauma. Many also said they had autism or mental health issues such as bipolar disorder that complicated their search for identity as teenagers.

Echoing what MacKinnon has found in his work, nearly all of these young people told Reuters that they wished their doctors or therapists had more fully discussed these complicating factors before allowing them to medically transition.

No large-scale studies have tracked people who received gender care as adolescents to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning. The studies that have been done have yielded a wide range of findings, and even the most rigorous of them have severe limitations. Some focus on people who began treatment as adults, not adolescents. Some follow patients for only a short period of time, while others lose track of a significant number of patients.

“There’s a real need for more long-term studies that track patients for five years or longer,” MacKinnon said. “Many detransitioners talk about feeling good during the first few years of their transition. After that, they may experience regret.”

In October, Dutch researchers reported results of what they billed as the largest study to date of continuation of care among transgender youths. In a review of prescription drug records, they found that 704, or 98%, of 720 adolescents who started on puberty blockers before taking hormones had continued with treatment after four years on average. The researchers couldn’t tell from the records why the 16 had discontinued treatment.

Gender-care professionals and transgender-rights advocates hailed the 98% figure as evidence that regret is rare. However, the authors cautioned that the result may not be replicated elsewhere because the adolescents studied had undergone comprehensive assessments, lasting a year on average, before being recommended for treatment. This slower, methodical approach is uncommon at many U.S. gender clinics, where patient evaluations are typically done much faster and any delay in treatment, or “gatekeeping,” is often believed to put youth at risk of self-harm because of their distress from gender dysphoria.

Dr Marianne van der Loos, the Dutch study’s lead author, is a physician at Amsterdam University Medical Center’s Center for Expertise on Gender Dysphoria, a pioneer in gender care for adolescents. “It’s important to have evidence-based medicine instead of expert opinion or just opinion at all,” van der Loos said.

Reliable evidence of the frequency of detransition and regret is important because, as MacKinnon, van der Loos and other researchers say, it could be used to help ensure that adolescent patients receive the best possible care.

“We cannot carry on in this field that involves permanently changing young people’s bodies if we don’t fully understand what we’re doing and learn from those we fail.” Dr Laura Edwards-Leeper, clinical psychologist and co-author of WPATH treatment guidelines for adolescents

A basic tenet of modern medical science is to examine outcomes, identify potential mistakes, and, when deemed necessary, adjust treatment protocols to improve results for patients. For example, only after large international studies analyzing outcomes for thousands of patients did researchers establish that implanted coronary artery stents were no better than medication for treating most cases of heart disease.

Stronger data on outcomes, including the circumstances that make regret more likely, would also help transgender teens and their parents make better-informed decisions as they weigh the benefits and risks of treatments with potentially irreversible effects.

“We cannot carry on in this field that involves permanently changing young people’s bodies if we don’t fully understand what we’re doing and learn from those we fail,” said Edwards-Leeper, the clinical psychologist and WPATH member. “We need to take responsibility as a medical and mental-health community to see all the outcomes,” she said in an interview.

As Reuters reported in October , thousands of families in the U.S. have been weighing these difficult choices amid soaring numbers of children diagnosed with gender dysphoria, the distress experienced when a person’s gender identity doesn’t align with their gender assigned at birth. They have had to do so based on scant scientific evidence of the long-term safety and efficacy of gender-affirming treatment for minors.

Concern about how to cope with the growing waiting lists at gender clinics that treat minors has divided experts. Some urge caution to ensure that only adolescents deemed well-suited to treatment after thorough evaluation receive it. Others argue that any delay in treatment prolongs a child’s distress and puts them at risk of self-harm.

Detransition defined

Detransitioning can mean many things. For those who transitioned socially, it may entail another change in name, preferred pronouns, and dress and other forms of identity expression. For those who also received medical treatment, detransitioning typically includes halting the hormone therapy they otherwise would receive for years.

Nor do all people who stop treatment regret transitioning, according to interviews with detransitioners, doctors and researchers. Some end hormone therapy when they have achieved physical changes with which they are comfortable. Some are unhappy with the side effects of hormones, such as male pattern baldness, acne or weight gain. And some are unable to cope with the longstanding social stigma and discrimination of being transgender.

Doctors and detransitioners also described the challenging physical and emotional consequences of the process. For example, patients who had their ovaries or testes removed no longer produce the hormones that match their gender assigned at birth, risking bone-density loss and other effects unless they take those hormones the rest of their lives. Some may undergo years of painful and expensive procedures to undo changes to their bodies caused by the hormones they took to transition. Those who had mastectomies may later undergo breast reconstruction surgery. As parents, they may regret losing the ability to lactate. Detransitioners also may need counseling to cope with the process and any lingering regret.

The impact can be social, too. In a study published last year in the Journal of Homosexuality, a researcher in Germany surveyed 237 people who had socially or medically transitioned and later detransitioned, half of them having transitioned as minors. Many respondents reported a loss of support from the LGBTQ community and friends, negative experiences with medical professionals, difficulty in finding a therapist familiar with detransition and the overall isolation after detransition.

“Many respondents described experiences of outright rejection from LGBT+ spaces due to their decision to detransition,” wrote Elie Vandenbussche, the study’s author, a detransitioner and at the time a student at Rhine-Waal University of Applied Sciences. “It seems reasonable to suspect that this loss of support experienced by detransitioners must have serious implications on their psychological well-being.”

In its new Standards of Care, released in September, WPATH cited Vandenbussche’s paper and a few others on detransitioning and continuation of care among younger patients. “Some adolescents may regret the steps they have taken,” the WPATH guidelines say. “Therefore, it is important to present the full range of possible outcomes when assisting transgender adolescents.”

However, Bowers, WPATH’s president, is among several gender-care specialists who say patients are ultimately responsible for choices they make about treatment, even as minors. They should not be “blaming the clinician or the people who helped guide them,” she said. “They need to own that final step.”

WPATH’s guidelines acknowledge the lack of research on long-term outcomes for youth who didn’t undergo comprehensive assessments, saying that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents” who receive treatment after careful evaluation. “Further, rates of reported regret during the study monitoring periods are low,” the guidelines say.

Specific treatment protocols for detransitioning are hard to find. WPATH’s guidelines don’t provide detailed advice to clinicians on treating patients who detransition. The Endocrine Society’s guidelines for gender-affirming care, published in 2017, don’t address the issue, either. The “question of discontinuing hormone treatment is beyond the scope covered by the current guideline,” an Endocrine Society spokeswoman said.

Some doctors think they – and patients – would benefit from more guidance. “We have guidelines to guide us in providing transition-related care, initiating hormones and managing them long-term. Equally as important would be having guidelines in deprescribing hormones in the safest way possible,” said Dr Mari-Lynne Sinnott, a doctor who attended MacKinnon’s symposium. She runs one of the only family medical practices in Newfoundland focused on gender-diverse people, who make up about half of her 1,500 patients.

“Sure of my identity”

Max Lazzara’s childhood in Minneapolis, Minnesota, was chaotic, with divorce, “moving around a lot, some emotionally abusive stuff at home,” she said. Her mother worked full-time, so Lazzara did most of the cooking, cleaning and caring for her little brother. She began to cut and burn herself as a means of coping and had tried to commit suicide three times before she entered high school, according to Lazzara and her medical records, which cite a history of bipolar disorder.

“The life of a woman was bleak to me,” Lazzara told Reuters. “I worried that I would have to get married to a man someday and have a baby. I wanted to run far away from that.”

In early 2011, when Lazzara was 14, she started questioning her gender identity. After discovering forums on Tumblr where young people described their transitions, she felt like something snapped into place. “I thought, ‘Wow, this could explain why my whole life felt wrong.’”

During the summer of that year, Lazzara changed her name and began experimenting with presenting as more masculine. It felt good to cut her hair and wear gender-neutral or men’s clothing. She took medications and received therapy to treat bipolar disorder. But it wasn’t enough to alleviate her distress. In April 2012, Lazzara was admitted to the hospital at the University of Minnesota after a fourth suicide attempt.

“I felt so strongly. I thought nothing would change my mind.” Max Lazzara, on her decision to medically transition at age 16

Three weeks later, she sought care at the university’s Center for Sexual Health, where she was diagnosed with gender identity disorder. Lazzara told the clinic she was “sure of my identity,” according to her medical records. She wanted hormones and surgeries, the records show, including a mastectomy, a hysterectomy, and liposuction to slim her legs and hips. She was horrified at her body, could not look down in the shower and felt “absolute dread at the time of menstrual cycle,” the records note.

“I felt so strongly. I thought nothing would change my mind,” Lazzara told Reuters.

Clinicians at the university warned families that their children were suicidal “because they are born in the wrong bodies,” Lazzara’s mother, Lisa Lind, told Reuters. “I thought, ‘I’ll do whatever it takes, so she doesn’t kill herself.’”

Lazzara started taking testosterone in the fall of 2012, at age 16. She was still binding her breasts – so tightly, she said, that her ribs deformed. After a man groped her on the street, she decided to have breast-removal surgery, tapping the college fund her grandmother had left for her to cover the nearly $10,000 cost.

Initially, Lazzara was happy with her transition. She liked the changes from taking testosterone – the redistribution of fat away from her hips, the lower voice, the facial hair – and she was spared the sexist cat-calling that her female friends endured. “I felt like I was growing into something I wanted to be,” Lazzara said.

But her mental health continued to deteriorate. She attempted suicide twice more, at ages 17 and 20, landing in the hospital both times. Her depression worsened after a friend sexually abused her. She became dependent on prescription anti-anxiety medication and developed a severe eating disorder.

During the summer of 2020, Lazzara was spiraling. She realized she no longer believed in her gender identity, but “I didn’t see a way forward.”

That October, Lazzara was working as a janitor in an office building in the Seattle area when she caught her reflection in a bathroom mirror. For the first time, she said, she saw herself as a woman. “I had not allowed myself to have that thought before,” she said. It was shocking but also clarifying, she said, and “a peaceful feeling came over me.”

Then she began to ponder her sexuality. In middle school, she had crushes on girls. After her transition, she identified as a transgender man who was bisexual. Now, she realized, she was a lesbian.

Lazzara stopped taking testosterone. She later asked her doctor in the Seattle area for advice, but he seemed unsure about how to proceed. She found a new doctor and recently sought laser hair removal on her face.

Lazzara told Reuters she now realizes that gender treatment was not appropriate for her and that it took a toll on her physical and mental health. “I do wish my doctors had said to me, ‘It’s OK to feel disconnected from your body. It’s OK to like girls. It’s OK to be gender non-conforming.’”

Since Max Lazzara detransitioned, many in the online transgender community who embraced her a decade ago have distanced themselves from her, and she has received hateful messages on social media.

Her original gender-care providers at the University of Minnesota declined to comment. In a statement, the university’s medical school said “gender-affirming care involves a carefully thought-out care plan between a patient and their multidisciplinary team of providers.”

Lazzara recently found the before-and-after pictures of her torso on the website of the surgeon who performed her mastectomy in 2013. She had given him permission to post the images because he was proud of the outcome. Seeing her body as it once was stunned her. “I saw my breasts before I got them removed. That’s my 16-year-old body,” she said. “I had no ability at that age to be in my own body in my own way.”

Since revealing she detransitioned, Lazzara said, many in the online transgender community who embraced her a decade ago have distanced themselves from her, and she has received hateful messages on social media. Now, when she sees someone come out online as detransitioned, she sends them a private message of support. “I know how lonely and alienating it can be,” she said.

“Shut up,” detransitioner

Transgender people are frequently subjected to harassment, abuse and threats online. And as Lazzara’s experience shows, so are detransitioners. In recent posts on TikTok, users took turns telling detransitioners to “shut up,” and mocked, attacked and blamed them for perpetuating harm on the transgender community.

Diana Salameh, a transgender woman, film director and comedian from Mississippi, posted a TikTok video on Oct. 1 to “all the so-called transgender detransitioners out there.” Detransitioners “are just giving fuel to the fire to the people who think that no trans person should exist,” she said in the video. “You people who jumped the gun, made wrong decisions that you should actually feel embarrassed for, but you want to blame somebody else.” In closing, she said, “I think you all need to sit down and shut the fuck up!”

Salameh told Reuters she posted the video because detransitioners spread the false idea “that nobody can be happy after transition,” and right-wing opponents of youth gender care are using their stories “to fuel their agendas.”

Earlier this year, K.C. Miller, a 22-year-old in Pennsylvania who was assigned female at birth, began wrestling with how she felt about her medical transition.

Miller initially sought treatment for gender dysphoria when she was 16 from the adolescent gender clinic at Children’s Hospital of Philadelphia. In September 2017, Miller met with Dr Linda Hawkins, a counselor and co-founder of the hospital’s gender clinic, for the first of two 90-minute visits. During that session, Miller told Hawkins she had wanted to be a Boy Scout as a kid and “always felt like a tomboy,” according to Hawkins’ notes in Miller’s medical records, reviewed by Reuters. Miller also told Reuters that as a young girl she was attracted to other girls, but didn’t feel she could pursue those relationships because her family’s church didn’t accept homosexuality.

Miller’s case had further complications. Hawkins noted that Miller had an extensive history of sexual abuse by a family member starting at age 4, and that as a result, Miller had already been diagnosed with anxiety and post-traumatic stress disorder. Miller had been admitted to a psychiatric hospital for 10 days because of suicidal thoughts in late 2016.

While in the hospital, Miller told her mother she wished she wasn’t a girl “because then the abuse would not have happened,” Hawkins wrote. Elsewhere in the records, Hawkins noted that “Mom expresses concern that the desire to be male and not female may be a trauma response.”

Miller, her mother and Hawkins met again seven weeks later. Miller had continued to have suicidal thoughts. She had taken medication for depression and anxiety and was working with a therapist, Hawkins noted. By the end of that second visit, Hawkins concluded that, “in spite of” Miller’s trauma from abuse, the 16-year-old “has been insistent, persistent and consistent” in thinking of herself as male.

Hawkins referred Miller to a local gender clinic to receive testosterone. Miller got a mastectomy about six months later.

But medical treatment didn’t offer the relief she sought. Her body started to change due to the hormones, yet Miller didn’t feel better. Instead, she cycled through bouts of depression. She passed as a young man, but “something felt off. It felt like I was putting on an act.”

Then Miller began reading the stories posted online by young detransitioners. Parts of their experiences resonated with her. “I absolutely would not have done this if I could go back and do it again,” Miller told Reuters. “I would have worked through therapy and would be living my life as a lesbian.”

Miller said Hawkins should have done a more thorough evaluation of all of Miller’s mental health issues and shouldn’t have recommended treatment so quickly.

Her mother, who asked not to be identified to protect her privacy, told Reuters that providers assured her that Miller’s distress was related to her gender identity and that gender-affirming care would reduce the risk of suicide.

A spokesman for Children’s Hospital of Philadelphia declined to comment, citing patient privacy.

Sitting in her car in early October, Miller let out years of frustration in a video posted on Twitter. She told viewers she felt she looked too masculine to detransition. She described how testosterone thinned her hair. “I don’t see me personally being able to come back from what’s happened,” she said in the video.

The video went viral, registering nearly four million views within days and igniting an avalanche of comments. Two days after Miller’s post, Alejandra Caraballo, a transgender woman, LGBTQ-rights advocate and clinical instructor at Harvard Law School’s Cyberlaw Clinic, wrote on Twitter: “The detransition grift where you complain about transitioning not making you look like a greek god but you also aren’t actually detransitioning yet because you don’t feel like your birth gender and you follow a bunch of anti-trans reactionaries that want all trans people gone.”

Caraballo told Reuters she reacted to Miller’s video because those types of detransition stories are “outlier examples being used by many on the anti-trans side to undermine access to gender-affirming care. They aren’t representative of detransitioners on the whole.”

In other posts and direct messages, some transgender people Miller had once idolized made fun of her appearance and criticized her decisions. One person made a death threat.

A few weeks later, Miller said she stopped taking testosterone, began to feel suicidal and sought psychiatric care. She uses female pronouns among friends, but still presents as a man in public.

In its Standards of Care, WPATH says many detransitioners “expressed difficulties finding help during their detransition process and reported their detransition was an isolating experience during which they did not receive either sufficient or appropriate support.”

In May, Dr Jamison Green, a transgender man, author and former president of WPATH, said he was encouraged when about 30 medical professionals attended an online WPATH seminar he and other gender-care specialists helped lead. The session was intended to help providers better serve detransitioners and other patients with an evolving gender identity.

“I wish people in the transgender community would be less judgmental about people who change their mind,” Green said. “Transgender people, especially when they are newer to the community, can be really brutal to people for not conforming. I really think it’s harmful for everybody.”

Word search pitfalls

Ever since the first clinic to offer gender care to minors in the United States opened in Boston 15 years ago, none of the leading providers have published any systematic, long-term studies tracking outcomes for all patients.

In 2015, the National Institutes of Health funded a study to examine outcomes for about 400 transgender youth treated at four U.S. children’s hospitals, including the gender clinic at Boston Children’s Hospital. Researchers have said they are looking at “continuation of care.” However, long-term results are years away.

That has left a small assortment of studies to guide clinicians in this emerging field of medicine. The results of these studies suggest a wide range of possibilities for rates of detransitioning, from less than 1% to 25%. The research provides even less certainty about the incidence of regret among patients who received medical treatment as minors. And the studies have serious drawbacks.

Two of the largest ones, which found that 2% or less of people who transitioned experienced regret, focused on Europeans who primarily initiated treatment as adults. Experts caution that the results, because of the differences in maturity and life experiences between adults and adolescents, may have limited relevance as an indicator of outcomes for minors.

Researchers acknowledge that studies that follow patients for only a short time may underestimate detransition and regret because evidence indicates some people may not reach that point until as long as a decade after treatment began. Some studies also lose track of patients – a recurring challenge as minors age out of pediatric clinics and have to seek care elsewhere.

Even the choice of search terms can trip up researchers, as apparently happened in a study published in May by Kaiser Permanente, a large integrated health system based in Oakland, California.

That study examined 209 patients who underwent gender-affirming mastectomies as minors between 2013 and 2020 in Kaiser’s northern California region. Its authors searched the patients’ medical records for words such as “regret,” “dissatisfaction,” “unsatisfied” and “unhappy” as indicators of regret. They didn’t look for the term “detransition,” according to the study.

Their search yielded two patients who had expressed regret, or less than 1% of the group studied. The two patients, identified as nonbinary, had top surgery at age 16, and expressed regret within a year and a half.

Reuters found two other patients in the region covered by the study who don’t match those characteristics and whom the Kaiser researchers apparently missed. Both have been outspoken about their detransitions.

One is Max Robinson, who was 16 when she sought gender care at Kaiser in 2012. Her pediatric endocrinologist prescribed a puberty blocker and later testosterone.

The doctor monitored Robinson’s hormone levels, wrote numerous letters to help Robinson change her legal gender from female to male, and recommended a plastic surgeon in San Francisco, Robinson’s medical records show. “I have no reservations recommending Max as a well adjusted candidate for breast reduction,” the Kaiser endocrinologist wrote to the surgeon in May 2013. Max had the surgery six weeks later, when she was 17.

After the surgery, Robinson felt better. But within a year, her mental health issues, including anxiety and depression, had escalated, medical records show.

In November 2015, three years after starting testosterone and two years after her surgery, Robinson told the Kaiser physician she was now seeing that she wasn’t interested in taking hormones any longer. “I’m no longer going to be using testosterone, so I don’t need further appointments or for those prescriptions to be active,” she wrote to the doctor. Two months later, she asked Kaiser to provide a letter confirming her detransition so she could change her legal records back to female. Kaiser obliged.

“The whole experience alienated me from my doctors,” she told Reuters.

Robinson began to speak publicly about her decision to detransition and in 2021 published “Detransition: Beyond Before and After,” a book in which she details her own process of medical transition and detransition.

The other patient was Chloe Cole. According to a letter of intent to sue that her lawyers sent to Kaiser in November, Cole was 13 when a Kaiser doctor in 2018 put her on a puberty blocker, followed a few weeks later by testosterone, for her gender-affirming treatment.

At 15, Cole told Reuters, she also wanted top surgery. In an interview, she and her father said the doctors at Kaiser readily agreed, though he wanted to wait until she was older.

“They were so adamant,” he said. He recalled the doctors telling him: “‘At this age, they definitely know what their gender is.’” The father asked not to be named out of concern that speaking publicly might jeopardize his employment. Detransition, he said, “wasn’t really discussed as a possibility.”

In June 2020, a Kaiser surgeon performed a mastectomy on Cole, according to the letter of intent to sue. That was a month before her 16th birthday. Less than a year later, Cole said, she began to realize she regretted her surgery and medically transitioning in general after a discussion in school about breastfeeding and pregnancy.

Cole said that when she discussed her decision to detransition with her gender-care specialist at Kaiser, “I could tell that I made her upset that I was so regretful,” Cole said in an interview. Eventually, the doctor offered to recommend a surgeon for breast reconstruction, Cole said, “but that’s something I’ve decided to not go through with.”

Cole has begun speaking out publicly in support of measures to end gender-affirming care for minors, appearing often on conservative media and with politicians who back such bans.

In the letter of intent, Cole’s lawyers said Kaiser’s treatment “represents gross negligence and an egregious breach of the standard of care.”

Steve Shivinsky, a spokesman for Kaiser Permanente, declined to comment on the care provided to Cole and Robinson or whether they were included in the study, citing patient privacy.

In a statement, he said Kaiser’s “clinicians are deeply interested in the outcomes of the care we provide and the individual’s state of health and wellbeing before, during and beyond their gender transition.” For adolescents seeking gender-affirming care, he said, “the decision always rests with the patient and their parents and, in every case, we respect the patients’ and their families’ informed decision to choose one form of care over another.”

The Kaiser researchers followed up with patients in their study an average of 2.1 years after surgery. “The time to develop postoperative regret and/or dissatisfaction remains unknown and may be difficult to discern given that regret is quite rare,” the researchers wrote.

A change of perspective

MacKinnon, the assistant professor of social work, grew up as what he calls “a gender-nonconforming tomboy” in a small Nova Scotia town. After getting his degree in social work, he medically transitioned at 24 when he started taking testosterone. “It was a very slow build,” MacKinnon said of his transition. He didn’t identify as transgender as a child.

As a young researcher in Toronto, MacKinnon was drawn to work that exposed the barriers transgender people face in getting medical care and navigating daily life, interviewing clinicians and patients about their experiences. More recently, he turned his attention to detransition and regret.

In August 2021, MacKinnon published a paper in which he and his co-authors wrote that there was “scant evidence that detransition is a negative phenomenon” for patients that would justify limiting access to gender-affirming treatment. That conclusion angered many of the detransitioners he would later need to win over.

Michelle Alleva, a 34-year-old detransitioner in Canada, criticized MacKinnon’s study in a blog post as another effort by gender-care supporters to whitewash the pain of regret and assuage clinicians’ fears of malpractice lawsuits. Another detransitioner complained on Twitter that the word “regret” was put in quotes in the paper, undermining its legitimacy in her opinion.

Still skeptical that regret was a significant issue, MacKinnon in the autumn of 2021 embarked on his latest study and began talking to more people about their decisions to detransition. In July, he published a paper based on formal interviews with 28 of the more than 200 detransitioners he and his colleagues have found.

A third expressed either strong or partial regret about their transition. Some said their transitions should have proceeded more slowly, with more therapy. Others expressed regret about the lasting impact on their bodies. Some said their mental health needs weren’t adequately addressed before transitioning. “They felt like their consent wasn’t informed because they didn’t initially understand what was going on that might have explained their feelings and suffering,” MacKinnon told Reuters.

The patients’ stories brought MacKinnon round to the view that the gender-care community needs to address regret, adjust treatment to reduce its incidence, and provide better support for detransitioners. “Some of what I’ve learned about detransitioners is identifying cracks in the gender-affirming care system, particularly for young people,” he said.

In September, MacKinnon presented his findings to a small but attentive crowd at WPATH’s annual conference in Montreal. A few weeks later, he shared his research more widely on Twitter. “We need to listen to and learn from the experiences of detransitioners, not silence them,” he wrote.

Some people applauded his work. Others criticized it. Robyn D., who identified as “quietly trans,” replied on Twitter: “Transphobia disguised as academic opinion is the most poisonous of them all.” She didn’t respond to requests for comment from Reuters.

At his November symposium, MacKinnon didn’t encounter the blowback from clinicians that he had expected. In fact, he accepted an invitation from one to speak about detransition at her medical practice.

Alleva, who had criticized MacKinnon’s earlier study, was also there, one of the scores of detransitioners MacKinnon and his colleagues have talked to. She medically transitioned 12 years ago and then detransitioned in 2020 after a mastectomy, a hysterectomy and years of testosterone. She had refused to participate in his research because she didn’t trust MacKinnon, but over the summer, they began talking.

“He reminded me of my old trans friends who I don’t speak with anymore,” Alleva said. “He actually listened to me.”

Few answers: A survey of the science on gender-care outcomes for youths

No large-scale, long-term studies have tracked the incidence of detransition and regret among patients who received gender-affirming treatment as minors. Studies that are available yield a wide range of results for various definitions of detransition, regret or continuation of care. Due to their limitations, the studies lack definitive answers. Here is an overview of frequently cited research:

Research institutions

Karolinska Institute, Karolinska University Hospital, Sahlgrenska University Hospital

The study’s authors said they found a 2.2% regret rate  among patients who had gender reassignment surgeries in Sweden from 1960 to 2010. The researchers found 681 people who filed a government application for a legal change in gender and received surgery, which was available only to patients 18 and older. Among that group, 15 people later reversed their decisions and filed a “regret application” with a national health board.

Limitations

The authors said the regret rate for patients in the last decade reviewed, from 2001 to 2010, may have increased over time. “The last period is still undecided since the median time lag until applying for a reversal was 8 years,” according to the study.

Far fewer adolescents received gender-affirming medical care prior to 2010. Also, the assessment phase for patients in the study was much longer than what Reuters found most youth gender clinics in the U.S. offer today. The gender-care specialists in Sweden did approximately one year of evaluation before recommending any treatment, according to the study.

10.1007/s10508-014-0300-8

Netherlands

Research institution

Amsterdam University Medical Center

February 2018

This study found a rate of regret of less than 1%  among transgender men and women “who underwent gonadectomy,” or removal of the testes or ovaries, from 1972 to 2015 in the Netherlands.

The authors found 14 cases of regret out of 2,627 patient cases reviewed. The earliest any of the 14 started hormone treatment was 25. Until 2014, transgender people in the Netherlands had to undergo gonadectomy to change the gender on their birth certificate. For surgery, patients were required to be at least 18 and on hormone therapy for at least a year.

The study didn’t report regret among patients who didn’t undergo surgery. Thirty-six percent of patients overall didn’t return to the clinic after several years of treatment and were lost to follow-up.

People treated in the last decade of the study may report regret later. “In our population the average time to regret was 130 months, so it might be too early to examine regret rates in people who started with (hormone therapy) in the past 10 years,” the authors wrote.

https://www.jsm.jsexmed.org/article/S1743-6095(18)30057-2/fulltext

October 2022

Researchers found that 98% of 720 adolescents who started on puberty blockers before taking hormones had continued with treatment after four years on average. The authors used a nationwide prescription drug registry in the Netherlands to track whether patients were still taking hormones.

The researchers didn’t identify the reasons why 2% of patients had stopped treatment . The adolescents in the Netherlands also went through a lengthy assessment process, a year on average, before being recommended for medical treatment. For that reason, the Dutch researchers say, their results may not be applicable more broadly.

“There might be a difference because of that diagnostic phase,” said Dr Marianne van der Loos, the study’s lead author and a physician at Amsterdam University Medical Center’s Center for Expertise on Gender Dysphoria. “If you don’t have that, maybe more people will start treatment and reconsider it later on because they didn’t get help during that phase by a mental health professional.”

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(22)00254-1/fulltext

United States

Children’s Mercy Kansas City, Uniformed Services University, U.S. Department of Defense

The authors said that more than a quarter of patients  who started gender-affirming hormones before age 18 stopped getting refills  for their medication within four years. The study examined 372 children of active duty and retired service members in the U.S. military insurance system, known as TRICARE.

It’s unclear why patients stopped their medication because the study only examined pharmacy records. The researchers said the number of patients who stopped hormones is likely an overestimate because they couldn’t rule out that some patients got hormones outside of the military system, perhaps at college or with different health insurance.

The follow-up period for many patients was relatively short. The researchers examined patients enrolled from 2009 to 2018, but 58% of the patients started hormones in the last 22 months of the study.

https://doi.org/10.1210/clinem/dgac251

United Kingdom

University College London Hospitals, Leeds Teaching Hospitals, Tavistock and Portman clinic – National Health Service Trust

Researchers found that 90 patients, or 8.3% , of 1,089 adolescents referred for gender-affirming care at endocrinology clinics no longer identified as gender-diverse , either before or after starting on puberty blockers or hormones. The review spanned patients who were treated from 2008 through 2021.

The authors noted the 8.3% figure may be an underestimate because 62 additional patients, or 5.4% of all participants, moved away or didn’t follow up with the clinics.

https://adc.bmj.com/content/107/11/1018

Fenway Institute, Massachusetts General Hospital

Drawing on the 2015 U.S. Transgender Survey, the authors found that 13.1%  of 17,151 respondents had detransitioned  for some period of time.

Some of the common reasons respondents provided were pressure from a parent (35.6%), pressure from their community or societal stigma (32.5%), or difficulty finding a job (26.9%). Nearly 16% of respondents cited at least one “internal driving factor, including fluctuations in or uncertainty regarding gender identity,” according to the study. Half of the people who reported detransitioning had taken gender-affirming hormones.

By design, the authors said, all respondents identified as transgender at the time of survey completion, and the survey wasn’t intended to capture people who detransitioned and no longer identified as transgender.

https://www.liebertpub.com/doi/10.1089/lgbt.2020.0437

Youth in Transition

By Robin Respaut, Chad Terhune and Michelle Conlin

Photo editing: Corinne Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

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Experience: I regret transitioning

I saw that it wasn’t being female that was stopping me from being myself; it was society’s perpetual oppression of women

W hen I was a little girl living in the Midlands, I used to say, “When I grow up, I want to be a boy.” I even used to wee standing up. I loved playing football, but when I was about seven my friends said I had to stop because I was a girl. I told them I didn’t see what difference that made, and one of them pulled his shorts down and showed me. A sickening feeling washed over me: something about me, and my body, was wrong.

These feelings became more powerful as I grew older. When I saw my chest changing I was horrified; I developed an eating disorder to try to delay puberty, cut my hair short and started binding my chest. I was depressed and tried to kill myself. At 14, I was admitted to a psychiatric hospital for a couple of months.

My parents were stunned, and tried to convince me to start embracing life as a woman. They arranged for someone to teach me how to apply makeup, hoping that if I learned to look more like other girls, I would feel more like them.

It wasn’t until I was 15 that I found out about transitioning. Everything fell into place: this was who I was. I realised I could have the body I wanted. When I went to my GP, aged 17, I was told I was too old to refer to children’s services and too young to be seen as an adult; I didn’t get my first appointment until three months after my 18th birthday.

After months of waiting and appointments, none of which included counselling, I finally started on testosterone gel, later switching to injections. It was a huge thing when, at university, my voice broke, and my figure started changing: my hips narrowed, my shoulders broadened. It felt right. Passing as a man, I felt safer in public places, I was taken more seriously when I spoke, and I felt more confident.

Then I had chest surgery. It was botched and I was left with terrible scarring; I was traumatised. For the first time, I asked myself, “What am I doing?” I delayed the next steps of hysterectomy and lower surgery, after looking into phalloplasty and realising that I was going to need an operation every 10 years to replace the erectile device. Trans issues were starting to be written about in the media, and I understood that people would always be able to recognise me as having transitioned. I just wanted to be male, but I was always going to be trans.

At the same time, there was a significant change in how I felt about my gender. Reflecting on the difference in how I was treated when people saw me as a man, I realised other women were also held back by this. I had assumed the problem was in my body. Now I saw that it wasn’t being female that was stopping me from being myself; it was society’s perpetual oppression of women. Once I realised this, I gradually came to the conclusion that I had to detransition.

I have come off testosterone and, as my body has resumed production of its own hormones, I have become someone female who looks like a man. I will always have a broken voice and will never regrow breasts, but my hips and thighs are getting bigger. Being male was more comfortable for me, but remaining on hormones means I would have continued to focus on my body as the problem – when I don’t believe it belongs there. What feels easiest isn’t always what’s right.

I made the best possible decision in poisoned circumstances, and if I hadn’t had treatment when I did, I might not be alive. But I do feel very sad when I think of my fertility: I want to be a parent one day, but it’s likely that being on testosterone has made that more difficult. I’m now in my late 20s and won’t know until I try to have children.

I feel happy for those people transition has helped, but I think there should be more emphasis on counselling, and that it should be seen as the last resort. Had that been the case for me, I might not have transitioned. I was so focused on trying to change my gender, I never stopped to think about what gender meant. Ultimately, I feel hopeful for the future. I’ve seen that I have an immense capacity to change and grow, even in very difficult circumstances. That is who I am.

As told to Moya Sarner.

Do you have an experience to share? Email [email protected]

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Regret after gender-affirming surgery under 1%: Study

( NewsNation ) — Regret among transgender and gender-diverse people who receive gender-affirming care is rarer than believed, according to a new study.

Three researchers at Johns Hopkins University are urging the medical community to dismiss the belief — often held among conservatives — that people who undergo the surgery regret it later in life.

That argument is not supported by science, according to the article published Wednesday in the journal JAMA Surgery .

Researchers Harry Barbee, Ph.D. ;  Bashar Hassan, M.D. ; and Fan Liang, M.D. , conducted a retrospective look at the limited studies examining gender-affirming care and found that the “regret rate” is less than 1%.

“This rate of surgical regret among (transgender and gender diverse) patients appears to be substantially lower than rates of surgical regret following similar procedures among the broader population, including cisgender individuals,” the authors wrote in the report summary.

“In fact, 1 systematic review found that the average prevalence of surgical regret was 14.4% among all research studies analyzed, which the authors suggested was relatively low,” they added.

The idea that people regret undergoing gender-affirming surgery has been used by lawmakers across the country to justify bans on the procedure. There are a total of 22 states that have laws restricting gender-affirming care, according to the Movement Advancement Project , though some of those are being challenged in court.

On Friday, Ohio Gov. Mike DeWine vetoed a bill that would have banned gender-affirming surgery for transgender youth. However, the bill could still go into effect if Ohio’s House of Representatives and Senate override the governor’s veto with a three-fifths vote.

Still, the governor noted he will proceed with drafting administrative rules to ban gender-affirming surgery on minors. DeWine said he is also instructing his administration to collect data on trans health care and to combat clinics that don’t provide adequate mental health counseling.

The research from Johns Hopkins aligns with best practice guidelines from multiple medical associations, including the American Academy of Pediatrics , the American Medical Association and the American Psychological Association .

The researchers suggest that the low regret rate may be a reason people decide to have the surgery in the first place.

“That reduction in regret also may (be) due to careful implementation of existing evidence-based, multidisciplinary guidelines and standards of care for those who are (transgender or gender diverse), such as requiring a well-documented history of gender dysphoria (feeling mismatch between biological sex and gender identity),” according to a news release from Johns Hopkins .

For the latest news, weather, sports, and streaming video, head to NewsNation.

What if you "succeed" in completing a TS transition,

but did it for the wrong reasons?

Yep, you get the idea!

This is one place you do NOT want to go!

Deutsch , Espa�ol , Fran�ais (new) , עברית (Hebrew) , Portugu�s , Русский

Renée Richards

Dani Bunten Berry

Sandra MacDougall

Samantha Kane

First consider the case of Renée Richards , who transitioned and had SRS in 1975 at age 40, and who was widely outed the next year as the "transsexual tennis player". Renee's story was widely reported in the media, and her story initially did a lot of good by announcing to a new generation of young TS girls that "sex change was possible", just as Christine Jorgensen's case had done in the mid-1950's. In 1983, she went on to write an autobiography about her transition entitled "Second Serve" , which stimulated further notoriety about her situation and about transsexualism in general, especially regarding whether postop women should be allowed to participate as women in competitive sports.

Unfortunately, the extensive publicity about Renée's "sex change", publicity which she largely brought on herself, generated a widespread public image of her as a "transsexual" rather than a woman. The mystique surrounding her case widely propagated the image that postop women are not women after all, but are instead whatever "Renée Richards" is.

"I wish that there could have been an alternative way, but there wasn't in 1975. If there was a drug that I could have taken that would have reduced the pressure, I would have been better off staying the way I was -- a totally intact person. I know deep down that I'm a second-class woman. I get a lot of inquiries from would-be transsexuals, but I don't want anyone to hold me out as an example to follow. Today there are better choices, including medication, for dealing with the compulsion to crossdress and the depression that comes from gender confusion. As far as being fulfilled as a woman, I'm not as fulfilled as I dreamed of being. I get a lot of letters from people who are considering having this operation...and I discourage them all."

- Ren�e Richards, "The Liason Legacy", Tennis Magazine , March 1999.

"She calls the 2004 decision of the International Olympic Committee, which allows transsexuals to compete, �a particularly stupid decision"" . . . "Better to be an intact man functioning with 100 percent capacity for everything than to be a transsexual woman who is an imperfect woman.�"

- Ren�e Richards, as quoted in " The Lady Regrets ", New York Times, February 1, 2007

Then we have those who "change sex" on a whim and have the financial means to do so, then afterwards have regrets and sue everyone in sight who "did this to them" - while not taking any responsibility whatsoever for their own actions.

For example, consider the case of "Samantha Kane", and then think about the damage that this impulsive person has done to himself and about the harm he is now doing to trans women everywhere by his irresponsible actions - both in transitioning and then in lashing out as those who tried to help him in the first place.

(Sam Hashimi => Samantha Kane => Charles Kane)

For more information on this case, see:

http://www.transgenderzone.com/features/changemeback.htm

http://www.bbc.co.uk/health/tv_and_radio/onelife_prog3.shtml

For a more extensive discussion about cases of "regrets", and also about groups of religious zealots and anti-gay ideologues who sometimes prey on these cases - smothering them with attention to get them to suddenly de-transition and then sue everyone in sight - see Christine Beatty's page entitled Transsexualism, Regrets and "Reparative Therapy" :

http://www.glamazon.net/transsexual-regrets.html

See also Joanne Herman's article "Transsexual Regret", The Advocate , March 13, 2007:

http://www.joanneherman.com/Trans_101_regret.html

Furthermore, those at risk for very difficult social transitions should realize that SRS will not in and of itself somehow miraculously "make them a woman in other people's eyes".  After all, the only people who see your genitalia are those whom you are intimate with (and your physicians, etc.) and thus SRS by itself will not affect the general reactions of those around you.  In cases where serious difficulties are expected in social transition, it might be wise to give FFS priority over SRS, because FFS has a much more profound effect on the reactions of others to one's transition.

Suddenly transitioning and then undergoing SRS on a whim is an especially bad idea, no matter how much money, influence, or power one has with which to make it happen. Seek counseling instead.  Learn about the alternatives.  Slow it down.  Listen to the advice of  Dani Berry and reflect on the case of Samantha Kane above.

Lynn Conway

["SRS Warning" Version of 4-09-05; update of 3-16-07]

[Return to Lynn's SRS page]

See Lynn "TS Women's Successes Page"

[Lynn's Homepage]

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How common is transgender treatment regret, detransitioning?

FILE - South Dakota Republican Rep. Jon Hansen speaks during a news conference at the state Capitol, Tuesday, Jan. 17, 2023, in Pierre, S.D. Hansen is pushing a bill to outlaw gender-affirming health care for transgender youth. (AP Photo/Stephen Groves, File)

FILE - People gather in support of transgender youth during a rally at the Utah State Capitol Tuesday, Jan. 24, 2023, in Salt Lake City. Utah lawmakers on Friday, Jan. 27, 2023, gave final approval for a measure that would ban most transgender youth from receiving gender-affirming health care like surgery or puberty blockers. (AP Photo/Rick Bowmer, File)

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Many states have enacted or contemplated limits or outright bans on transgender medical treatment, with conservative U.S. lawmakers saying they are worried about young people later regretting irreversible body-altering treatment.

But just how common is regret? And how many youth change their appearances with hormones or surgery only to later change their minds and detransition?

Here’s a look at some of the issues involved.

WHAT IS TRANSGENDER MEDICAL TREATMENT?

Guidelines call for thorough psychological assessments to confirm gender dysphoria — distress over gender identity that doesn’t match a person’s assigned sex — before starting any treatment.

That treatment typically begins with puberty-blocking medication to temporarily pause sexual development. The idea is to give youngsters time to mature enough mentally and emotionally to make informed decisions about whether to pursue permanent treatment. Puberty blockers may be used for years and can increase risks for bone density loss, but that reverses when the drugs are stopped.

Sex hormones — estrogen or testosterone — are offered next. Dutch research suggests that most gender-questioning youth on puberty blockers eventually choose to use these medications, which can produce permanent physical changes. So does transgender surgery, including breast removal or augmentation, which sometimes is offered during the mid-teen years but more typically not until age 18 or later.

Reports from doctors and individual U.S. clinics indicate that the number of youth seeking any kind of transgender medical care has increased in recent years.

HOW OFTEN DO TRANSGENDER PEOPLE REGRET TRANSITIONING?

In updated treatment guidelines issued last year, the World Professional Association for Transgender Health said evidence of later regret is scant, but that patients should be told about the possibility during psychological counseling.

Dutch research from several years ago found no evidence of regret in transgender adults who had comprehensive psychological evaluations in childhood before undergoing puberty blockers and hormone treatment.

Some studies suggest that rates of regret have declined over the years as patient selection and treatment methods have improved. In a review of 27 studies involving almost 8,000 teens and adults who had transgender surgeries, mostly in Europe, the U.S and Canada, 1% on average expressed regret. For some, regret was temporary, but a small number went on to have detransitioning or reversal surgeries, the 2021 review said.

Research suggests that comprehensive psychological counseling before starting treatment, along with family support, can reduce chances for regret and detransitioning.

WHAT IS DETRANSITIONING?

Detransitioning means stopping or reversing gender transition, which can include medical treatment or changes in appearance, or both.

Detransitioning does not always include regret. The updated transgender treatment guidelines note that some teens who detransition “do not regret initiating treatment” because they felt it helped them better understand their gender-related care needs.

Research and reports from individual doctors and clinics suggest that detransitioning is rare. The few studies that exist have too many limitations or weaknesses to draw firm conclusions, said Dr. Michael Irwig, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston.

He said it’s difficult to quantify because patients who detransition often see new doctors, not the physicians who prescribed the hormones or performed the surgeries. Some patients may simply stop taking hormones.

“My own personal experience is that it is quite uncommon,” Irwig said. “I’ve taken care of over 350 gender-diverse patients and probably fewer than five have told me that they decided to detransition or changed their minds.”

Recent increases in the number of people seeking transgender medical treatment could lead to more people detransitioning, Irwig noted in a commentary last year in the Journal of Clinical Endocrinology & Metabolism. That’s partly because of a shortage of mental health specialists, meaning gender-questioning people may not receive adequate counseling, he said.

Dr. Oscar Manrique, a plastic surgeon at the University of Rochester Medical Center, has operated on hundreds of transgender people, most of them adults. He said he’s never had a patient return seeking to detransition.

Some may not be satisfied with their new appearance, but that doesn’t mean they regret the transition, he said. Most, he said, “are very happy with the outcomes surgically and socially.”

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

• Vol 9, No 7 (April 15, 2021) /
• Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Sasha Karan Narayan 1^ , Rayisa Hontscharuk 2 , Sara Danker 3 , Jess Guerriero 4 , Angela Carter 5 , Gaines Blasdel 6 , Rachel Bluebond-Langner 6 , Randi Ettner 7 , Asa Radix 8 , Loren Schechter 9,10,11 , Jens Urs Berli 12

1 Department of Surgery, Oregon Health and Science University , Portland, OR , USA ; 2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center , Chicago, IL , USA ; 3 Division of Plastic Surgery, University of Miami Miller School of Medicine , Miami, FL , USA ; 4 Transgender Health Program, Oregon Health & Science University , Portland, OR , USA ; 5 Primary Care, Equi Institute , Portland, OR , USA ; 6 NYU Langone Health, New York, NY , USA ; 7 University of Minnesota , Minneapolis, MN , USA ; 8 Callen-Lorde Community Health Center , New York, NY , USA ; 9 The University of Illinois at Chicago , Chicago, IL , USA ; 10 Rush University Medical Center , Chicago, IL , USA ; 11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital , Chicago, IL , USA ; 12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University , Portland, OR , USA

Contributions: (I) Conception and design: S Danker, JU Berli; (II) Administrative support: SK Narayan, S Danker, JU Berli; (III) Provision of study materials or patients: S Danker, JU Berli; (IV) Collection and assembly of data: SK Narayan, S Danker, JU Berli; (V) Data analysis and interpretation: SK Narayan, J Guerriero, L Schechter, JU Berli, R Hontscharuk; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

^ ORCID: 0000-0003-1283-7847.

Background: A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

Methods: This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

Results: The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions: In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Keywords: Transgender surgery; transgender regret; detransition; reversal surgery; retransition; gender-affirming surgery

Submitted Sep 02, 2020. Accepted for publication Feb 07, 2021.

doi: 10.21037/atm-20-6204

Introduction

Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.

The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:

• The current literature regarding the etiology of regret following gender-affirming surgery;
• The experience of surgeons regarding requests for surgical reversal.

Based on these results, the authors propose a classification system for both type and etiology of regret.

It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).

A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.

Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.

Statistical analysis

Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.

Narrative literature review

A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.

Ethical statement

This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Survey results

Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).

Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .

Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).

Literature review

Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.

Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.

Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).

Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).

Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.

While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).

As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.

Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.

Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.

Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).

Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.

True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.

Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.

Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.

Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.

Associated definitions

Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.

Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.

Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.

Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).

Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.

Special considerations

We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.

A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.

Limitations

The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.

Conclusions

Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.

Acknowledgments

The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.

This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.

Funding : None.

Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.

Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204

Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204

Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.

Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/ .

• Lane M, Ives GC, Sluiter EC, et al. Trends in Gender-affirming Surgery in Insured Patients in the United States. Plast Reconstr Surg Glob Open 2018;6:e1738 [ Crossref ] [ PubMed ]
• Ross A. Gender Confirmation Surgeries Rise 20% in First Ever Report: American Society of Plastic Surgeons. American Society of Plastic Surgeons, Press Releases, 2017.
• Padula WV, Baker K. Coverage for gender-affirming care: Making health insurance work for transgender Americans. LGBT Health 2017;4:244-7. [ Crossref ] [ PubMed ]
• Canner JK, Harfouch O, Kodadek LM, et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg 2018;153:609-16. [ Crossref ] [ PubMed ]
• Walinder J, Lundstrom B, Thuwe I. Prognostic Factors in the Assessment of Male Transsexuals for Sex Reassignment. Brit J Psychiat 1978;132:16-20. [ Crossref ]
• Eldh J, Berg A, Gustafsson M. Long-term follow up after sex reassignment surgery. Scand J Plast Reconstr Surg Hand Surg 1997;31:39-45. [ Crossref ] [ PubMed ]
• Blanchard R, Steiner BW, Clemmensen LH, et al. Prediction of regrets in postoperative transsexuals. Can J Psychiatry 1989;34:43-5. [ Crossref ] [ PubMed ]
• Blank RJ. The partial transsexual. Am J Psychother 1981;35:107-12. [ Crossref ] [ PubMed ]
• Edgerton MT Jr, Langman MW, Schmidt JS, et al. Psychological considerations of gender reassignment surgery. Clin Plast Surg 1982;9:355-66. [ Crossref ] [ PubMed ]
• Lothstein LM. The postsurgical transsexual: empirical and theoretical considerations. Arch Sex Behav 1980;9:547-64. [ Crossref ] [ PubMed ]
• Hadj-Moussa M, Ohl DA, Kuzon WM Jr. Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery. Sex Med Rev 2018;6:607-17. [ Crossref ] [ PubMed ]
• Horbach SE, Bouman MB, Smit JM, et al. Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques. J Sex Med 2015;12:1499-512. [ Crossref ] [ PubMed ]
• Kuiper B, Cohen-Kettenis P. Sex reassignment surgery: a study of 141 Dutch transsexuals. Arch Sex Behav 1988;17:439-57. [ Crossref ] [ PubMed ]
• Landen M, Walinder J, Lundstrom B. Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatr Scand 1996;93:221-3. [ Crossref ] [ PubMed ]
• Lawrence AA. Factors Associated with Satisfaction or Regret Following male-to-Female Sex Reassignment Surgery. Arch Sex Behav 2003;32:299-315. [ Crossref ] [ PubMed ]
• Meyer JK, Reter DJ. Sex reassignment. Follow-up. Arch Gen Psychiatry 1979;36:1010-5. [ Crossref ] [ PubMed ]
• Nelson L, Whallett EJ, McGregor JC. Transgender patient satisfaction following reduction mammaplasty. J Plast Reconstr Aesthet Surg 2009;62:331-4. [ Crossref ] [ PubMed ]
• Papadopulos NA, Lelle JD, Zavlin D, et al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med 2017;14:721-30. [ Crossref ] [ PubMed ]
• Pfafflin F. Regrets After Sex Reassignment Surgery. Journal of Psychology & Human Sexuality 1993;5:69-85. [ Crossref ]
• Pfäfflin F, Junge A. Geschlechtsumwandlung. Abhandlungen zur Transsexualität. Schtattauer, 1992.
• Ross MW, Need JA. Effects of adequacy of gender reassignment surgery on psychological adjustment: a follow-up of fourteen male-to-female patients. Arch Sex Behav 1989;18:145-53. [ Crossref ] [ PubMed ]
• Sorensen T. A follow-up study of operated transsexual females. Acta Psychiatr Scand 1981;64:50-64. [ Crossref ] [ PubMed ]
• Sorensen T. A follow-up study of operated transsexual males. Acta Psychiatr Scand 1981;63:486-503. [ Crossref ] [ PubMed ]
• Zavlin D, Schaff J, Lelle JD, et al. Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes. Aesthetic Plast Surg 2018;42:178-87. [ Crossref ] [ PubMed ]
• Poudrier G, Nolan IT, Cook TE, et al. Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study. Plast Reconstr Surg 2019;143:272-9. [ Crossref ] [ PubMed ]
• Carroll RA. Outcomes of Treatment for Gender Dysphoria. Journal of Sex Education and Therapy 1999;24:128-36. [ Crossref ]
• Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 2018;15:582-90. [ Crossref ] [ PubMed ]
• Landen M, Walinder J, Hambert G, et al. Factors predictive of regret in sex reassignment. Acta Psychiatr Scand 1998;97:284-9. [ Crossref ] [ PubMed ]
• Lindemalm G, Korlin D, Uddenberg N. Long-term follow-up of "sex change" in 13 male-to-female transsexuals. Arch Sex Behav 1986;15:187-210. [ Crossref ] [ PubMed ]
• Pfäfflin F, Junge A. Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991. Symposion Publishing in the Book Section of The International Journal of Transgenderism, 1998.
• James SE, Herman JL, Rankin S, et al. The Report of the 2015 US Transgender Survey. Washington, DC: National Center for Transgender Equality, 2016.
• Hage JJ, van Turnhout AA. Long-term outcome of metoidioplasty in 70 female-to-male transsexuals. Ann Plast Surg 2006;57:312-6. [ Crossref ] [ PubMed ]
• Schechter LS, D'Arpa S, Cohen MN, et al. Gender Confirmation Surgery: Guiding Principles. J Sex Med 2017;14:852-6. [ Crossref ] [ PubMed ]
• Deutsch MB. Gender-affirming Surgeries in the Era of Insurance Coverage: Developing a Framework for Psychosocial Support and Care Navigation in the Perioperative Period. J Health Care Poor Underserved 2016;27:386-91. [ Crossref ] [ PubMed ]
• Baum J, Brill S, J B, et al. Supporting and caring for our gender expansive youth. Human Rights Campaign Foundation and Gender, 2013.
• James SE, Herman J. The Report of the 2015 US Transgender Survey: Executive Summary. National Center for Transgender Equality, 2017.

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10 trans people share how their life satisfaction has changed after transition

Transgender people overwhelmingly describe their lives after transitioning as “happier,” “authentic” and “comforting” despite a deluge of state legislation in recent years that seeks to restrict their access to health care and other aspects of life.

Over the last three years, nearly half of states have passed restrictions on transition-related medical care — such as puberty blockers, hormone therapy and surgery — for minors. Supporters of the legislation have argued that many transgender people later regret their transitions, though studies have found that only about 1%-2% of people who transition experience regret.

Earlier this year, the 2022 U.S. Transgender Survey — the largest nationwide survey of the community, with more than 90,000 trans respondents — found that 94% of respondents reported that they were “a lot more satisfied” or “a little more satisfied” with their lives.

Transgender Day of Visibility, observed on March 31, is an annual awareness day dedicated to celebrating the accomplishments of trans people and acknowledging the violence and discrimination the community faces. NBC News asked transgender people from across the country to share how their life satisfaction has changed after transition. Out of two dozen respondents, all but one said they feel more joy in their lives. Here are some of their stories.

Ash Orr, 33

Morgantown, west virginia.

Orr, who is the press relations manager for the National Center for Transgender Equality, the trans rights advocacy group that conducted the nationwide survey, began socially transitioning in his mid-20s, and at 33, he received gender-affirming top surgery.

“The impact of this surgery … has been life-changing,” Orr said. “My body now feels like a comforting and familiar home, a place I had yearned for and have finally returned to.”

When Orr isn’t working, he loves immersing himself in nature, whether that’s through gardening or playing pickleball with friends. He also chases tornadoes in the Midwest — “Yes, like the movie ‘Twister’!” he said.

“My transition journey has been a profound lesson in self-discovery,” Orr said. “It has shown me that there are countless versions of myself waiting to be unearthed.”

Criss Smith, 63

After transitioning, Smith said he felt a sense of congruence between his internal sense of self and his external presentation.

“I was so broken and uncertain, and now I have a profound sense of relief, empowerment and alignment with how I feel and being the best human possible,” he said. Smith said he worked on Wall Street in financial services for more than 30 years for major companies including Merrill Lynch and JPMorgan Chase. He now works as a substitute teacher for the New York City Department of Education.

“My mind is more at rest and I am at ease with every moment,” Smith said of life after his transition. “A joy fills my soul that I never thought possible before. I am truly living a full human experience presenting all of my authenticity. I live in a liberation garden.”

Gavin Grimm, 24

Hampton roads, virginia.

Grimm was the plaintiff in a landmark 2020 court case in which the 4th Circuit U.S. Court of Appeals upheld the rights of transgender students to use the school bathrooms that aligned with their gender identities. In 2021, the Supreme Court declined to hear the case and allowed the circuit court’s decision in Grimm’s favor to stand.

Now, nearly three years later, Grimm plans to go back to college to become a middle or high school teacher. He came out and began his transition in 2013, and “to date, I have absolutely zero regrets,” he said.

“While I do still struggle with unrelated strife in my personal life, the ability to be myself fully and completely for the last decade has given me the strength and joy that I have needed to carry on,” Grimm said. “Despite these challenges, I remain very, fundamentally happy. Exquisitely happy, even, in just finding small joy each day in a world where I had the ability to access myself.”

Dani Stewart, 57

Springfield, missouri.

Stewart said transitioning was “a life saver” for her and that she feels more confident than she ever has before.

“I feel like I belong in society,” said Stewart, who said she was formerly a news desk producer at CNN and worked for various TV stations. “However, dark clouds remain for all trans people. We need better and more representation in media. We need to see more of ourselves integrated with the world around us.”

Andrea Montañez, 58

Orlando, florida.

Montañez said her son and her co-workers both observed the same change in her after she transitioned in 2018: They said they noticed her smile.

“You always were a nice person, but we didn’t know you could smile,” Montañez recalled her co-workers telling her. “I lost a lot, but I won freedom and happiness.”

Montañez is the director of advocacy and immigration at the Hope CommUnity Center in Orlando and is involved in advocating against legislation targeting LGBTQ people in Florida — work that she said has helped her build community, find happiness and “bring the magic” to her and others’ lives.

“We are a gift,” she said. “Trans people are a gift.”

Elizabeth ‘Lizzy’ Graham, 34

Silver spring, maryland.

In 2015, Graham said she kept a bag of women’s clothes in her car so that when she finished her shift at work as a tech support professional, she could drive to a Starbucks and change in the bathroom. She was also driving for Uber at the time, and one day she decided to dress as herself so she could practice coming out to her passengers before she came out to her family.

She came out fully in the summer of 2015, and said her gender dysphoria, or the distress caused by a misalignment between one’s sex assigned at birth and gender identity, went away with time.

“Once I began my transition journey and began living full time, my focus and productivity improved,” she said. “Many friends and people I know who knew me prior to transitioning said that they could tell I was happier now that I came out and was living my authentic life.”

Now, Graham is a service coordinator who helps autistic children who receive Medicaid-funded services, and she leads a support group for transgender people in her area.

Jordan Reid, 27

Harper woods, michigan.

Reid said her coming out as a transgender woman in 2022 happened alongside a number of other life changes. She had just gotten divorced, and then she dropped out of medical school, or, as she says, “exploded” all of her career aspirations.

But the last two years have been much happier, she said. Reid is back in school studying computer science and data science, and has rekindled her love for music. She has played guitar since she was 10, but said she stopped because she didn’t like her singing voice. Now, she sings in the shower every day.

“On paper, it may look like I have taken quite a few steps back in life,” Reid said. “In reality, what’s on paper doesn’t matter one bit if, instead of sacrificing my joy, I get to spend the majority of my time not only smiling, but truly feeling a reason to smile.”

Tiffany Jones, 35

Newark, new jersey.

Jones, who works in an Amazon warehouse, said transitioning has helped reduce her suicidal ideation.

“I am happy that I am living as my unapologetically authentic self,” Jones said, adding that her transition “helped me improve my self-confidence” and allowed her to be more creative. She now writes poetry, cosplays as anime characters and has a stronger support network, she said.

She said she worries about her personal safety as a Black trans woman, but “I just think about the positive things in life, and that there’s so much out there in the world, so much inspiration.”

Kylie Blackmon, 26

Azle, texas.

Blackmon said her life changed dramatically when she came out in 2021.

“It seemed like everything clicked mentally with me. No longer was I burdened with living a lie and having that weigh on me constantly,” she said. However, she said things are harder socially in her small Texas town of about 15,000 people, northwest of Fort Worth. She said she faces transphobia from her co-workers, and that some of her family members don’t understand her identity.

She’s currently training to be a phlebotomy technician, which is someone who collects and tests blood samples, and in her free time she enjoys doing makeup, shopping and spending time with her friends.

Cristina Angelica Piña, 23

Central valley, california.

Piña, a consultant, said that being trans can be difficult, but that “underneath this pain, there is an unfettered joy, power and beauty.”

“My existence reminds people of choice,” said Piña, who enjoys fashion, poetry, rap, cooking and spending time with her friends and her dog, Bella. “We have the autonomy to decide how we exist in the world. We have the freedom to present ourselves in a way we see fit — not what others have placed upon us.”

For more from NBC Out,  sign up for our weekly newsletter .

Jo Yurcaba is a reporter for NBC Out.

I Had Gender Confirmation Surgery. Here's What Happened Before, During And After.

Guest Writer

The day after I turned 19, I underwent gender confirmation surgery, or GCS, in Bangkok. An announcement like this is usually followed by a slew of questions, often from total strangers, including, “Do you have a vagina now? If so, does it ... you know ... work? Did it hurt?” and many others.

Actually, when people find out you’re transgender ― whether you’ve surgically transitioned or not ― the questions start almost immediately and they pretty much never stop. They’re often deeply personal questions ― ones you would never dream of asking a cisgender (non-trans) person, but because society typically treats trans bodies as public property, we don’t receive the privacy or dignity that everyone else receives.

Even if these inquiries come from a place of genuine compassion or curiosity, being trans can be an incredibly painful and traumatic experience, and when trans people are asked invasive, often quite rude questions by people who have no right to the answers, it only exacerbates that pain and trauma.

That said, I understand the curiosity that drives these questions. I really do. I understand why it can all seem a bit confusing at first. And because I believe that if there’s a silver bullet for prejudice, ignorance and hate, it’s education, I’ve decided to set the record straight, once and for all, from start to finish. No holds barred. No punches pulled. I will be completely honest about what I went through and how things changed when I came out the other side.

I’m going to do my best to answer these questions so that maybe people will stop asking them. Of course, everyone’s transition is different, and every experience of GCS is unique. Everyone has their own story. This is mine.

“If you’ve ever been through puberty or menopause, you know how awful sudden hormonal shifts can be. By the end of it all, I was physically and emotionally exhausted, and the hardest part hadn’t even begun yet.”

GCS is not something you do on a whim. In Australia, where I live, I needed to have lived full-time as my true gender and be on hormone replacement therapy or HRT, for one full year before I was even allowed to apply for surgery, and it is never legally performed on minors. After that, both a psychologist and a psychiatrist had to sign documents certifying that this procedure was not only very much desired but medically necessary for me.

I also had to choose a surgeon. After an exhaustive search, I chose Dr. Chettawut Tulayaphanich, who specializes in treating gender dysphoric patients and who came highly recommended by my endocrinologist. While there are surgeons in Australia who offer GCS, surgeons overseas, particularly in Thailand, tend to be more affordable and have more experience with the procedure.

After that, all my travel documents had to be lined up — no mean feat when you’re halfway through legally changing your name. I had to undergo a battery of physical, blood and STD tests. My results were then emailed to the clinic overseas. Around this time, I also had to stop taking my HRT until after the surgery. If you’ve ever been through puberty or menopause, you know how awful sudden hormonal shifts can be. By the end of it all, I was physically and emotionally exhausted, and the hardest part hadn’t even begun yet.

My surgery was scheduled for Friday, May 25, 2018. Between the flights, the hotel and the surgery itself, the bill came to about $20,000 AUD. I landed in Bangkok at 2:00 a.m. on the Sunday before my surgery. The following week was a barrage of more tests, consultations and preparation for what was to come. On Tuesday, I was ordered to fast until Friday.

On Wednesday, I had my big consultation with the surgeon himself. I had to take off my clothes in front of a room full of strangers (and my mother) and have the most intimate parts of my body examined, probed and photographed. Dr. Chettawut explained to me the exact process of the operation using multiple, very detailed, very realistic diagrams. You can read more about this process and see one of those diagrams here .

The most common method for creating a neo-vagina is a “penile inversion” technique where the genitals are, just as the name implies, inverted. In my case, the procedure was a little more complicated. Rather than being inverted outright, the genitals are removed and then reutilized to create different parts of the neo-vagina. The vaginal lining is made up of scrotal tissue and groin skin grafts. Because of this, unlike many other post-op trans women, my vagina can self-lubricate thanks to the preservation of certain secretory glands around the urethral and vaginal opening. Penile and prepuce skin was used to construct an anatomically accurate labia minora. The result is a vagina that looks and functions, sans periods and childbirth, more or less identically to that of a cis woman.

On the day of the operation, a car picked me up from my hotel and took me to the clinic. I surrendered my clothes and my phone and lay down on a gurney and waited to be wheeled into the operating theater. You may not believe me, but at that moment, I wasn’t scared ― not even a little bit. Maybe I was too exhausted to be afraid. Or maybe it was because I would rather have died on that operating table than go on living in the body into which I’d been born.

At 2:58 p.m., the nurses wheeled me into the operating theater, and the anesthesiologist placed a breathing mask on my face. I remember making a bad joke about the taste of the gas in my mouth as the lights went dim and I drifted into unconsciousness.

When I woke up, everything was a blur. The voices I heard sounded like they were far away, and I could feel the hands of the nurses on my body as they moved me from the operating table to a gurney. I felt absolutely nothing between my legs. I couldn’t move or speak.

They wheeled me to a small room outside the operating theater, and someone said something about checking on me later. Then I was left alone in the dark. I remember feeling thirsty, and I found myself struggling to breathe. Every breath felt too shallow, like I couldn’t get enough air into my lungs. I drifted in and out of sleep, content to simply lie still in the dark. At that point, there was no pain ― that came later.

The next day, I was moved to my own room and finally given water to drink. After that, I was gradually allowed to start eating again. Soon, the pain started. At first, it was a dull ache, but within 24 hours, it had become an unbearable agony that radiated out from the surgery site up through my entire abdomen.

I spent three or four days at the clinic before being moved back to my hotel. My daily routine consisted of taking several different kinds of painkillers and antibiotics at breakfast, lunch, dinner and bedtime, and watching a lot of Netflix to ease the boredom in between my doses. The idea was to medicate me enough so that I would be comfortable during the day and sleep through the night, but the painkillers always wore off too quickly. Each night became a grueling marathon of agony, and I would wait, desperate for the morning ― and my next set of pills ― to arrive.

I slept in stops and starts during the day, when the pills softened my excruciating pain into a strong but bearable ache. I cried at least once a day when I was alone, sometimes from the pain, sometimes from missing my partner, who was waiting for me back home in Sydney. Often, I found myself crying for no reason at all.

Each day, I was visited by nurses from the clinic. After about a week, I was told it was time for me to start dilation. For the uninitiated, when a seven-inch hole is created in your body, your body treats it like a wound and tries to close it up. Obviously, that would defeat the purpose of GCS, so the vagina is kept open using glass cylinders called dilators. I was given five of them, numbered zero to four, all about eight inches long, ranging from one and a half centimeters to about one and a half inches in width. Thanks to the technique my surgeon used, my vagina was able to accommodate a little more than seven inches in depth. Many trans women get five inches, sometimes even less. It all comes down to the skill of the surgeon, how diligent you are about sticking to your dilation schedule, and luck.

“After about a week, I was told it was time for me to start dilation. For the uninitiated, when a seven-inch hole is created in your body, your body treats it like a wound and tries to close it up.”

The process began with the nurses performing the dilation, and after that, it would be up to me. That first time, when the gauze packing was taken out of my vagina and that first, narrow glass rod (about the width of a large pen) was placed inside me, I lay back on the bed and caught my breath as I stared at the ceiling. It hurt a little, but not as much as I’d expected.

The sensation of something being inside my new vagina was beyond description. The novelty, the strangeness of it, the sudden sense of my mind and body being in harmony with one another after so many years of dissonance ... I can only imagine it might compare to how Dorothy felt stepping into Oz and seeing her sepia world turn to color. For the first time, I felt the reality of my new body set in, and despite everything, at that moment, I felt utterly breathless with joy.

One thing I expected after the surgery, but which nothing could have prepared me for, was the bleeding that I experienced after the gauze was removed. The amount of blood I lost over the next several months was almost unimaginable. When someone tells me I’ve never had a period and therefore I can’t possibly imagine what it must be like to be a “real” woman, I like to joke that I did have periods, I just got all of them at once. Every time I limped to the bathroom, a trail of blood followed me there and back. I changed my pads twice a day for a month, and every morning, the hotel staff would come and change my sheets which, despite the extra-absorptive pads I wore overnight, were soaked through with a massive pool of blood.

Two weeks later, a week before I was set to return home to Australia, the nurses noticed something off about how I was healing and I had to go back under the knife.

The first time I was operated on, I received general anesthesia. This time, I was awake and the anesthesia was local. It took three separate needles in my new vagina to administer the numbing agent, and even with it, over the next hour and a half, I felt everything, and I mean everything , as my new vagina was cut apart, rearranged and stitched back together. It was and remains the single most painful experience of my life.

By some miracle, I was still able to go home the following week. The second surgery had gone well, and I was starting to heal properly. I could now walk short distances with the aid of a walking stick but I still needed a wheelchair at the airport to make it to the plane. It took another two months before I was even close to being fully healed.

I’ve since read many accounts by other trans women about what dilation was like for them. Some of them almost never have to dilate after seven or eight months. A lot of them say the pain was negligible as they continued to dilate to keep their vagina open. I wasn’t so lucky. The best way I can describe dilating after I left Thailand is to liken it to inserting a serrated knife seven inches deep into an open wound and then holding it there for two and a half hours. Even now, four years later, I still need to dilate for one hour a day to maintain my depth and elasticity. The pain started to taper off after about three months, and I barely think about it now. It’s as much a part of my day as brushing my teeth and taking a shower. It seems strange now to think that this isn’t the body I was born into.

A lot of people have made headlines ― not just recently, but for years now ― talking about GCS and transgender people more broadly. Almost all of them have one thing in common: They’ve never actually been through it. I’d be willing to bet they’ve never even spoken to someone who has. I have been through it ― and it was harder than words could ever describe. It was terrifying. It was expensive. And it was the best thing I have ever done for myself.

I say this to all readers, but especially to any who might be thinking about undergoing GCS themselves: It doesn’t fix everything. When you’re finally healed and you go back to your day-to-day life, you’re still, at your core, the same person you were before GCS. You don’t live the rest of your life in a state of perpetual bliss. But what did change for me is that now, when I look in the mirror or when I look down at my body, I see my body, not someone else’s. When someone touches me, I don’t flinch or feel ashamed and disgusted. When I feel the right parts between my legs, most of the time I don’t feel euphoric, but I feel OK, and after a lifetime of agonizing incongruity between my body and brain, just feeling OK is absolutely priceless.

So there you have it. Now, let’s quickly get a few of the other more common questions out of the way: Yes, it looks like a vagina; yes, I can have vaginal sex and orgasm; no, I can’t give birth; yes, it was absolutely, beyond a shadow of a doubt worth it.

Lastly, it’s important to note that not every trans person wants or needs to undergo GCS. Some trans people only go on HRT, and some only transition socially. Gender originates not in the body but in the brain. Studies have shown that the brains of trans people are structurally closer to those of the gender they identify with than that of the gender they were presumed to have at birth .

To say I was born with a female brain in a male body is not just an expression, it’s a material and scientific fact. Wanting to express yourself and live as your true gender is not, as Bill Maher so crassly put it , analogous to wanting to be a “pirate.”

There is no one right way to be trans, any more than there is one right way to be a cis man or woman. I needed GCS just to feel comfortable in my own body, but not everyone feels that way, and many people that do need it can’t access it.

It can cost $50,000 or more to undergo GCS in Australia, and for plenty of trans people — for whom rates of poverty and unemployment are significantly higher than the national average — even the $20,000 I paid (half of which my parents covered) is out of reach. It doesn’t mean their gender is any less valid or that they should be treated any differently.

“There is no one right way to be trans, any more than there is one right way to be a cis man or woman. I needed GCS just to feel comfortable in my own body, but not everyone feels that way, and many people that do need it can’t access it.”

I’m incredibly grateful to have been able to undergo GCS. It’s no exaggeration to say it saved my life, and the fact that it remains inaccessible to so many people who need it is heartbreaking.

Gender dysphoria can be painful, and for some of us, myself included, it’s unbearable without medical intervention. I’m also grateful to have a family that supported me both during and after the procedure. Too many trans people (some of whom I know personally) have been either shunned or abandoned outright by unsupportive families after coming out.

Everyone’s experience is different, but for me and many other people, being trans is hard, even without factoring in the stigma and hate that is still so rampant in our society. But that does not mean that trans people are broken. It doesn’t mean they’re oddities or freaks. We’re different, and different can be confusing. Different can be scary. It seems written into our DNA to be scared of what we don’t understand. But the more we know, the less confusing and scary these identities and experiences become. That’s why I wrote this. And there are resources available online, at your local bookstore and at LGBT community centers.

Ignorance isn’t a virtue. If you don’t understand something, educate yourself. Research, read, and if you know a trans person and if they’re comfortable with talking about their life, ask (politely). But be OK if they don’t want to answer your questions. Many trans people don’t, and the obligation shouldn’t be on us. We’re human beings and deserve to be treated as such. We deserve to be treated with respect and dignity, just like you.

Elizabeth Walker is a 23-year-old trans woman living in Sydney. She studies animation and works part-time as a freelance writer. She started transitioning at the age of 15 and hasn’t looked back. Her hobbies include photography, ice skating and trail hiking. She has a loving partner of four years and two fur babies that she loves with all her heart.

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Hong Kong’s new ID card policy on gender markers slammed for ‘violating right to bodily integrity’ of trans people

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Hong Kong activists and lawyers slammed a new policy governing the changing of gender on ID cards Wednesday, saying the rule shift, which follows a court decision, still requires invasive surgery.

The city’s top court decided in 2023 that it was unconstitutional for the government to require a person to complete full gender reassignment surgery before the “sex entry” on their ID card could be changed.

The policy presented “an unacceptably harsh burden on the individuals concerned”, the Court of Final Appeal ruled at the time.

But new rules revealed by authorities on Wednesday keep most of the existing surgical requirements — dropping only the need for applicants to remove their uterus and ovaries, or to construct a vagina.

Applicants must still submit proof of having completed surgeries to modify sexual characteristics such as removal of the breasts, penis and testes.

They must also show that they have experienced gender dysphoria, have lived as their preferred gender for at least two years and will do so for the rest of their lives, and have undergone hormonal treatments and will continue those treatments.

While lawyer Wong Hiu-chong for the activists behind the lawsuit last year — Henry Tse and an appellant identified as “Q” — welcomed the revised policy, she raised concerns about “the heavy emphasis” for blood tests and hormone levels reports being the core requirements.

“We do not see the justifications but the contravention of individuals’ rights by forcing them to take unnecessary medical tests and their right to privacy,” said Wong in a statement.

Advocacy group Quarks and the Hong Kong Trans Law Database said in a statement that they were “extremely disappointed”.

“The new policy continues to violate transgender people’s right to privacy and bodily integrity,” the groups said.

The policy imposes unequal surgical requirements, lacks clear medical standards and pathologises trans people, the groups added.

Human rights lawyer Mark Daly told AFP that the new policy would be open to further challenge, as it demands “an invasive procedure that is not necessarily medically required by many of the transgender community”.

‘Proportionate’

The 2023 court decision was hailed as a hard-fought victory for LGBTQ rights, but some activists complained afterwards that the ruling was not immediately implemented and that their ID card amendment applications had stalled.

The Immigration Department — which oversees identification and visa issues — said Wednesday it would process applications and “take the initiative to contact the relevant individual applicants for follow-up”.

But the statement also noted that “the sex entry on a Hong Kong identity card does not represent the holder’s sex as a matter of law”, without further explanation.

The Hong Kong government defended its policy changes on Wednesday, saying the eligibility criteria and requirements were “reasonable and proportionate” and came after “careful consideration” of the court’s ruling last year.

See also: Hong Kong trans activist Henry Tse fought for the right to be recognised as a man without full surgery – and won

Veteran pro-Beijing politician Regina Ip said the new policy was a sign of “progress”, as the department lowered the bar on the surgeries required.

“They have to establish a threshold -– it’s not any person coming up to the Immigration Department and saying, ‘I now feel I am male, not female.’ You have to satisfy certain medical requirements,” Ip told AFP.

Ip explained that the change of gender was limited to the ID card.

“Whether it entitles you to benefits under other laws… that’s a separate matter.”

Type of Story: News Service

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