The Urgency of Detransition Care

What we need from gender medicine, and why

Photo by lucas clarysse on Unsplash

Frank Smith only had to visit the gender clinic once. At 19, convinced that medical gender transition would improve his life and relationships, he self-diagnosed with gender dysphoria and saw a psychologist at Transactive—a Portland, Oregon clinic. She didn’t ask about his history of family dysfunction, his bipolar diagnosis, his drug dependency or his addiction to “sissy” porn, which encouraged male-to-female transition. Instead, he said she focused on a single detail from his childhood: he used to like to play dress-up with his sister. “[Transition] was an easy answer to some really deep and complex issues,” he told me.

The clinic handed him a document: a “roadmap” to transition, all of which would be covered by Oregon Medicaid. In his testimony to the Oregon State legislature, Smith described pressure from doctors to pursue increasingly complex medical transition interventions, with a prescription for cross-sex hormones in hand after a single 30-minute session, and surgeries easily booked with outdated referral letters. Despite his deep desire to parent biological children someday, he had an orchiectomy, removing his testicles, followed quickly by breast implants and injections of estrogens. He was scheduled to undergo a vulvaplasty, a surgery to remove the penis and create the appearance of a vulva (but no neovagina), but caught Covid.

As the process finally slowed down, he began to name the feeling that had been circulating inside him after “five harrowing years of that medical treatment”: regret. He called it “the hormonal catastrophe of having no testosterone in my body,” and said that after transition, “I was even worse.”

Smith detransitioned, as much as he physically could. But he found it almost impossible to get psychological or medical support. He told me he had to pay out-of-pocket, $2,000, for the implants to be removed, and could only afford local anesthesia.

Now, he testified, “I am permanently disfigured and weakened by [a doctor’s] attempt at feminizing my chest, so too by the destruction of my facial hair follicles. I have newfound anxiety in my natal sex. Neither will insurance cover prosthetic testicles, which costs up to $10,000.” He is now a permanent medical patient.

Smith is far from alone. While many insurance companies, and states which support gender-affirming care, cover transition—that is, “gender-affirming care,” getting them to cover detransition-treatment has proved nearly impossible, per the detransitioners I’ve spoken with on and off the record over the past two years. This despite the fact that transition and detransition often involve the same procedures, like breast removal, hormones, or electrolysis.

The difference is that, for detransitioners, the point of these interventions is to undo, as much as is physically possible, the effects of transition. Thus, the procedures are undertaken for different reasons: to align “gender identity” with natal sex, not the other way around. They don’t fit the model of “gender-affirming care,” which treats an incongruence between gender identity and sex. One could argue that the refusal to provide this care is sex discrimination.

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Detransitioners also have enormous trouble accessing psychological support. One detransitioner told me he was denied help because he was deemed to have an “unstable gender identity.” Another said she was pressured to identify as non-binary instead.

Some therapists are afraid to treat detransitioners. “There’s a stigma,” Smith told me. “Regular therapists are really afraid to touch it.” Despite the fact that he felt suicidal, Smith said he was ghosted and dropped by therapists. Instead, they’d refer him back to the clinics he’d already been to.

Well-intentioned anti-conversion therapy laws can make it seem as if anything other than affirmation is illegal, and many therapists believe the misinformation that affirmation, rather than exploration, is the healthiest approach—that gender dysphoria causes coexisting mental health problems, as opposed to being a symptom of them. Others may want to stop detransition but it implicates them in their clients’ suffering. (Genspect’s Beyond Transition does offer low-cost therapy to detransitioners.)

Carol, a 42-year-old detransitioner who lives in California, suffered from gender dysphoria since age 13. She believed that she was a “trans man trapped in a lesbian body,” and that transition would fix her mental health issues. Instead, “I just spun out and deteriorated more for the next four years until I was pretty much homebound because of severe panic attacks,” she told me. 

In 2018, she began taking an antidepressant. “It was like a fog had lifted from my brain,” she said. A year later, she detransitioned, and when she tried going to another therapist, that person insisted transition made people better. She was defensive, rather than curious or empathetic.

Carol realized that affirming therapists had hurt her, and couldn’t help her. “It was this very visceral, violated feeling,” Carol said. “It was fucking traumatic as hell.” 

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Meanwhile, as some states pass laws that prevent minors from medically transitioning, and others make it easier, few are thinking about detransitioners as they wage legislative battles.

Most states which have stopped allowing youth medical transition haven’t included provisions for what opponents call the “forced detransition” of minors. Some of those young people may be taken off cross-sex hormones and puberty blockers, which could involve psychological and physical impacts.

Some people are at least trying to make sure that those who choose to detransition, or who get hurt by gender-affirming prodedures, are supported. In Texas, Representative Jeff Leach offered up HB3502, which instructs insurance companies that paid for gender transition procedures to cover “all possible adverse consequences related to the enrollee’s gender transition procedure or treatment, including any short- or long-term side effects of the procedure or treatment.”

States promoting youth gender medicine sanctuary bills—like California, New York and Oregon—indemnify the practitioners, but do little to protect those who transition, making it harder for them to sue for malpractice. They do nothing to prepare or provide for those who might detransition, and who might want to hold practitioners who approved them for transition accountable. So on March 27, Oregon state Representative Ed Diehl, a Republican, proposed an amendment to HB2002, a bill to protect both abortion and medical gender transition. (Linking abortion and gender medical transition is a brilliant tactical move on the part of the original bill’s sponsors; no lefty could object to a bill requiring insurance companies operating in Oregon to provide abortion, even if they were iffy on youth gender medicine.)

Diehl’s amendment would make sure that detransition treatment be included in “gender transition” treatment, to help people like Smith.

This means including any “medically necessary procedure prescribed by a physical or behavioral health care provider as detransition treatment, including but not limited to:

(A) Breast reconstruction for an individual who had a bilateral mastectomy;

(B) Breast implant removal for an individual who received a breast implantation;

(C) Electrolysis for an individual suffering from unwanted facial or body hair as a result of taking testosterone;

(D) Physical or occupational therapy;

(E) Fertility services;

(F) Hormone replacement therapy for the purpose of realigning an individual’s gender identity and the individual’s sex assignment at birth if the individual previously underwent a gender-affirming treatment procedure that altered the individual’s ability to produce hormones consistent with the individual’s sex assignment at birth;

(G) Behavioral health care for trauma or other mental health impacts associated with detransition treatment; or

(H) Treatment for chronic pain or disabilities resulting from gender-affirming treatments, including but not limited to: “(i) Pelvic pain; “(ii) Pelvic prolapse; “(iii) Urinary tract infections; “(iv) Incontinence; “(v) Vaginal atrophy; “(vi) Premature menopause; “(vii) Surgical scar pain; “(viii) Sexual dysfunction; “(ix) Complications from surgeries, including hysterectomy, orchiectomy, penectomy, vaginoplasty, phalloplasty and oophorectomy; and “(x) Osteoporosis, osteopenia or osteoarthritic conditions following treatment with hormones known to adversely affect bone development.”

Diehl’s provision—which has a list of possible outcomes that could be listed in informed consent documents—was rejected by Democratic politicians who found detransitioners’ tales too horrendous to be credible. They believe transgender people, but not detransitioners.

This is unsurprising, considering the makeup of the Oregon legislature (so progressive that they’re regressive?). But it’s also disheartening. Why wouldn’t you want the best healthcare for people, even if they return identifying as the sex they are? Why are insurance companies responsible for transitioning but not what comes after? Lawmakers are supposed to do cost-benefit analyses, but they can’t if they’re unwilling to consider the costs.

There seem to be two reasons for not including detransition care. One is that everything about detransition is controversial, and progressives pushing these sanctuary state bills can’t touch it without becoming instantly radioactive to those they perceive as their voters. (I say perceive because I think the majority of non-radical Dems do not want bills that allow children to run away to other states and get cross-sex hormones without parental knowledge or consent.) The other, the proponents of youth gender medicine have said, is that the number of detransitioners is so small.

We have very little data on detransition. Maybe the rate was once quite low, when there were heavy restrictions on who could transition. But today we have exponential increases in those diagnosed with gender dysphoria, and those seeking medical transition. A recent study revealed a detransition rate of almost 7% after just one year, which the authors called a likely “underestimate.” A recent Reuters article noted that “results of these studies suggest a wide range of possibilities for rates of detransitioning, from less than 1% to 25%.” It would help to know just how many people transition, so we could figure out how many humans we’re talking about. But gender clinics are not required to do follow-up, nor are private doctors or clinics offering these medical interventions.

How many detransitioners are there? We don’t know.

One reason for that underestimate, in my opinion, is the reluctance of many detransitioners to speak out—and for good reason. They are shunned by their former communities, vilified, threatened, called names, accused of “grifting.”

Many are also traumatized by their transitions. Some are incredibly ashamed. I met two detransitioners recently who refused to say a single word about what they’d gone through, and one was still publicly identifying as trans. How do you collect data on such a cohort?

But perhaps more importantly: How do you help them?

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A 2021 study by Pablo Expósito-Campos notes: “Detransitioning can be as difficult as transitioning due to societal lack of understanding, social isolation, fear, shame, trauma, and the paucity of answers and resources for those who take that path.”

Expósito-Campos suggests differentiating between “core” and “non-core” detransitioners—those who detransition for internal reasons (that is, not being trans or not alleviating gender dysphoria) versus external reasons: stigma, shame, finances. He details what “core” detransitioners may need help with:

1) Obtaining information on how to safely stop HRT;

(2) Finding alternative, non-medical ways to cope with GD;

(3) Securing ongoing psychological support to deal with the possible distress, anxiety, shame or regret associated with the experience of detransition;

(4) Securing ongoing psychological support to address any other existing mental health issue;

(5) Understanding the origins of GD and the role that identifying as transgender and transitioning played in that person’s life;

(6) Receiving counseling on how to announce detransition to family and friends;

(7) Obtaining information about the possibilities of reversing some the physical changes derived from HRT and/or sex reassignment surgeries (SRS);

(8) Obtaining information on the possibility to change back one’s legal name and sex on the civil registry; and

(9) Accessing legal support in cases of possible medical malpractice—organizations such as the Gender Care Consumer Advocacy Network have been created with this purpose.

The World Professional Association for Transgender Health, or WPATH—an advocacy group which provides suggestions for transgender medicine, followed by some providers in the US—admits that clinicians must support detransitioners. The 8th version of their “Standards of Care” states explicitly: “It is vital that people who detransition, for any reason, be supported.” It also notes that “detransitioning may occur in young transgender adolescents and health care professionals should be aware of this. Many of them 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.”

However, almost any mention of detransition in the SOC8 is immediately followed by the insistence that it’s rare.

“It should be remembered, however, this is a rare occurrence and the literature shows consistently positive outcomes for the vast majority of TGD [transgender/gender-diverse] adults who transition to a gender that is comfortable for them, including those who receive GAMSTs [gender-affirming medical and/or surgical treatments].”

“The decision to detransition appears to be rare.”

“While the choice to detransition is proportionally rare, it is expected an overall increase in the number of adults who identify as TGD would result in an increase in the absolute number of people seeking to halt or reverse a transition. However, while the absolute numbers may increase, the percentage of people seeking to halt or reverse permanent physical changes should remain static and low.”

“Little research has been conducted to systematically examine variables that correlate with poor or worsened biological, psychological, or social conditions following transition; however, this occurrence appears to be rare.”

You get the idea. SOC8 also asserts that, “Estimates of the number of people who detransition due to a change in identity are likely to be overinflated due to research blending different cohorts. But other research asserts the estimates are underinflated, and the study they cite—Expósito-Campos’—doesn’t suggest overinflation.

Instead, the study stresses the need to research detransition deeply in order to make good decisions, and indicates that the affirmative model may be part of the problem. So is the conflation of a clinical diagnosis of gender dysphoria with a self-proclaimed transgender identity; those are not the same things. “Therefore, it is more important than ever that clinicians be honest and transparent with their patients about the known benefits, risks—biological, social, and psychological—and long-term consequences associated with each treatment option, which is the only way to ensure the obtention of meaningful informed consent,” writes Expósito-Campos.

Even trans people are urging us to listen to detransitioners. As a recent article by two trans men in The Atlantic notes, “Ignoring detransitioners’ experience isn’t just harmful to them; it also means that doctors and scientists miss out on much-needed data that could improve gender-affirming care for future patients.”

States that are making medical gender transition easier have a responsibility to make sure that care is well-executed—and that means including detransition care. Clinicians have a responsibility to share what is known, and unknown, about detransition. Any school that shares information about trans kids should share information about detransitioners, too.

That’s where the discussion can begin, but mostly there’s silence—or vehement pushback. How many media outlets covered “trans day of visibility” versus “detrans awareness day?” At what clinics do they hand out a roadmap for detransition? This is the time for proponents of gender-affirming care to stop denying detransition, or trying to reframe it as a harmless “gender journey,” and to listen to those who’ve been hurt—in order to reduce such hurt in the future.

Yet in Oregon, Representative Rob Nosse refused to consider Frank Smith’s story, instead suggesting that the doctor who helped him detransition by removing his breast implants should be investigated.

“It’s a warning,” Smith told me—a note cautioning doctors not to help detransitioners, and cautioning the rest of us to look away. But we can’t, and we shouldn’t, and we won’t be able to continue doing so: detransition lawsuit have already begun.

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