Transitioning to a medical scandal

Emily Wheater and Ellen Pasternack say the gender change lobby is failing young people who change their mind

This article is taken from the November issue of The Critic. To get the full magazine why not subscribe? Right now we’re offering three issue for just £5.

J.K. Rowling has recently been accused of transphobia for expressing concern about growing numbers of young people, women especially, who regret gender transition. In one of the politer admonishments Rowling received, economics professor Deirdre McCloskey wrote in Prospect that “she is mistaken . . . to believe that a sound reason to oppose gender change in say, children, is the alleged ‘accounts of detransitioners’.” McCloskey (who is trans) also referred to stories of detransition as “fairytales”.

In the UK, minors wishing to change gender may be prescribed “puberty blockers” if they have already started puberty, and children from 10 years old have been treated in this way. Cross-sex hormones can be prescribed from age 16, and surgical procedures carried out from 18. Detransitioners — individuals who regret or seek to reverse a gender transition — have become a bone of contention in the transgender culture wars. They are portrayed by organisations such as Stonewall, the UK’s foremost LGBT charity, and Mermaids, a UK-based charity working with trans-identifying minors, as a vanishingly rare phenomenon and the object of faux concern from conservatives who instrumentalise it to restrict access to transition.

We take issue with such minimisation, and share Rowling’s concerns. Detransitioners’ accounts cannot accurately be described as “alleged” or “fairytales”. The potential severity of the consequences faced by detransitioners necessitates scrutiny of the current treatment protocols for trans-identifying children.

Although rigorous data on the number of detransitioners is lacking, it is undeniable that there are people who have undergone a gender transition which they subsequently regret. A simple internet search reveals an abundance of examples. On social media site Reddit, the “detrans” forum, for detransitioners and people questioning their gender transition, has more than 15,000 members.

Almost every day new stories are posted by young people — mostly female — experiencing intense psychological pain due to the permanent effects of transition on their bodies. Many believe the causes of their unhappiness with their natal sex — sexual abuse, eating disorders, other mental health problems — were not adequately addressed by the professionals responsible for overseeing their transition.

Many personal anecdotes online point to detransitioners not returning to gender therapists

 Of course, many of these personal stories are uncorroborated. However, verifiable reports of women who have detransitioned are gaining greater profile. In October, 23-year-old detransitioner Keira Bell took the Tavistock and Portman Gender Identity Clinic to court over whether young people have the capacity to consent to puberty blocker treatment for gender dysphoria. Speaking on her motivations for joining the case against the clinic which treated her, Bell told us: “Once I began detransitioning I very quickly realised […] that young people have been and are currently being harmed, including myself.”

As a detransitioner in the public eye, Bell is not alone. Six detransitioned women (one of whom claims to know “around 100” others) were recently profiled for the Sunday Times by photojournalist Laura Dodsworth. With the meteoric increase over recent years in young people — girls especially — undergoing medical transition, Keira’s case looks likely to be the first of many.

November 2019 marked the launch of the Detransition Advocacy Network, a non-profit directing detransitioners towards support. Its founder Charlie Evans spoke as part of a panel of six detransitioned women aged 19-29, and afterwards wrote on Twitter that “combined we had 5 mastectomies, 2 hysterectomies, 2 ovariectomies, 20 years of testosterone”. These women are not “fairytales”. How many others are there? 

Trans organisations and progressive media outlets confidently claim that detransition is extremely rare. Stonewall has stated that of people who transition “less than one per cent” express regret. Mermaids has claimed that detransition rates are “very low”. Both support their claims with reference to a 2019 conference abstract that reports a 0.47 per cent regret rate, based on 3,398 adult patients who attended the Tavistock and Portman Charing Cross Gender Identity Clinic in 2016-2017. 

While an analysis of 3,398 patients sounds impressive, these individuals were not directly asked about feelings of regret. Instead, patient reports were “scanned electronically for words related to detransition or regret”. The abstract does not provide pertinent details about this patient group, such as what proportion had actually undergone any kind of transition.

No further details appear to have been published; this summary, which is not peer reviewed, is the only publicly available record of this research. It is therefore difficult to say what the number 0.47 per cent really reflects. This has not stopped Stonewall or Mermaids using this figure; unfortunately, these organisations are quoted uncritically by others who have not read, or understood, the abstract.

Another commonly cited figure for the rate of transition regret is 2.2 per cent, from a study of 767 Swedish adults who transitioned from 1960 to 2010, most of whom were male. However, extrapolations from groups treated prior to 2010, when transition was much rarer and sought largely by adult males, are of limited relevance to today’s detransitioners.

In the past decade young people referred to the NHS’s gender identity service have increased from 77 in 2009 to 2,590 in 2018-2019. The majority are female, with the number of girls seeking to change gender increasing even more dramatically than the number of young people in general. Similar patterns have been reported across the Western world.

These teenage girls seeking to transition in the last decade have a higher incidence of autism and mental health problems (such as eating disorders) than the population at large. They are more likely to be lesbian or bisexual and they often report having spent a lot of time online, talking to other trans-identifying young people and following trans influencers on social media. To assume that the motivations for transition and detransition in this cohort are the same as those of adult males transitioning decades ago is unjustified.

Published estimates of detransition rates based on gender identity clinic records or surveys aimed at the transgender population are unlikely to detect true detranstition rates. Many personal anecdotes online point to detransitioners not returning to gender therapists or endocrinologists (whom many resent and consider negligent) to inform them of their decision to detransition. Further, many no longer identify as transgender, and report that their decision to detransition has been a painful one, resulting in the loss of friends and withdrawal from trans communities. 

Little room is allowed for the idea that many young people come to accept the body they have

The true rate of detransition among this new and distinctive cohort will probably take years to become clear. It seems that women who detransition after identifying as trans as minors commonly do so in their twenties, while many of today’s young transitioners are not yet out of their teens; reported timelines from initiation of treatment to first expressions of regret range up to 22 years. In the absence of data specific to this new patient group, assertions that detransition is vanishingly rare remain just that: assertions.

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The progressive narrative on detransition holds that it is not only extremely rare but almost always the result of an unsupportive environment, rather than signalling inappropriate medical intervention. Stonewall’s website states that lack of family or social support, financial concerns, and institutional transphobia are the major motivators for detransition. This is backed up with decades-old research (based on 218 patients who underwent gender reassignment from 1972 to 1992) which is unlikely to be applicable to today’s profoundly different patient population. 

Exploration of the community in question suggests a picture very different from that painted by Stonewall. In 2016, detransitioned blogger Cari Stella shared an informal survey on social media groups for detransitioners. In two weeks she collected more than 200 responses from individuals who began transitioning at an average age of 17 but subsequently detransitioned.

Legal action: Detransitioner Keira Bell is suing the Tavistock Clinic over her gender change treatment

The most common reasons cited were “Found alternative ways to cope with dysphoria” (59 per cent), and “Political/ideological concerns” (64 per cent). Lack of family or social support, financial concerns, and institutional transphobia were among the least frequently selected reasons.

The large proportion claiming to have “found alternative ways to cope with dysphoria” contradicts the argument pushed by proponents of child transition that it is the only solution for gender dysphoria (the feeling of uncomfortable mismatch between a person’s observable sex and how they prefer to be perceived). Little room is allowed for the idea that many young people come to accept the body they have.

The long-term outlook for side effects such as vaginal atrophy is not know

The affirmative model of care practised by the NHS, which Keira Bell is challenging, holds that any young person who wishes it should be assisted to transition. The idea that intervention to modify their bodies should be a last resort is seen by some as akin to conversion therapy: an attempt, born of prejudice and doomed to failure, to suppress a child’s true nature. For this narrative to be maintained, detransition must happen only rarely and for reasons that do not draw attention to the prerequisite of detransition: transition itself.

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Detransition demonstrates that, for some patients, transition is not a permanent source of relief from gender dysphoria. Nonetheless, these patients are left with irreversible bodily alterations, possibly including loss of healthy organs, impaired sexual function and sterility. In any other medical context these would be considered extremely serious consequences of treatment. For comparison, look at the understandable reluctance of doctors to agree to sterilisation procedures for mature adult women who are certain they do not want to become pregnant.

For some clinicians, however, detransitioning may form part of a “healthy developmental trajectory” of a “dynamic” gender identity. This is how Dr Jack Turban, an American physician specialising in the care of minors with gender dysphoria, explains the case of a female patient who, aged 19, was diagnosed with gender dysphoria and given testosterone, but later detransitioned. Turban insists that, for her, medical transition was an “important part of her identity formation”, and that she does not mind the permanent changes to her body as they are “only cosmetic”. But was there really no other therapeutic approach that might have enabled her to overcome her distress towards her body without altering it?

Turban’s justification is surprising, given the lack of certainty regarding the long-term effects of testosterone treatment on the female body. Growth of facial hair, male-pattern baldness, voice deepening, and enlarging of the clitoris appear to be irreversible. The long-term outlook for side effects such as chronic pelvic pain, vaginal atrophy, and elevated risk of gynecological cancers is not known.

Vaginal atrophy, a painful condition more often associated with post-menopausal women, often results in a severely impaired sex life, and can also cause urinary incontinence. Speaking of her experience of vaginal atrophy, one of the women profiled by Laura Dodsworth in the Sunday Times said: “I wasn’t warned this could happen . . . I get random pains, like stitches, in my vagina and vulva . . . I hope that now I am not taking testosterone my body will recover and heal and function the way it should again, but we don’t know.”

In the US, girls as young as 13 have undergone mastectomy as part of a transition

For minors, puberty blockers are often described as a reversible “pause button” offering more time to make a decision about future cross-sex hormone treatment. However, the long-term physical, psychological and cognitive effects of delaying a physiologically normal puberty are unknown — something that has only recently been acknowledged by the NHS. Side-effects of this treatment in girls resemble menopausal symptoms. Some accounts indicate that children treated with puberty blockers prior to cross-sex hormones may retain less developed, pre-
pubescent genitalia and inability to experience adult sexual or reproductive function. 

While the permanence or impermanence of the changes wrought by testosterone and puberty blockers may be uncertain, there is no such uncertainty regarding the removal of body parts. Women who have had a hysterectomy will of course be infertile; if their ovaries are also removed they will be menopausal and may require decades of hormone replacement.

Some undergo a metoidioplasty or phalloplasty — complex procedures that construct a neophallus either from the clitoris, or, in the latter case, from tissue taken from the arm, thigh, or back — which may involve surgical closure or removal of the vagina. The most sought-after surgical procedure among female transitioners is double mastectomy (“top surgery”), to create the appearance of a male chest. In the US, girls as young as 13 have undergone mastectomy as part of a transition.

Any other medical intervention where patients experienced regret would bring into question whether the intervention was ethical

Medical professionals ordinarily treat the removal of body parts as a last resort. But in relation to the removal of breasts, cavalier attitudes are pervasive. In her book Unbound: Transgender Men and The Remaking of Identity, the American sociologist Arlene Stein writes: “If you decide that top surgery was a mistake, you can have implants, if you can afford to do so.”

At a 2018 conference, Johanna Olson-Kennedy, an American physician specialising in youth gender dysphoria, infamously said of teenagers undergoing mastectomy, “If you want breasts at a later point in your life, you can go and get them.” Breasts constructed from implanted silicone or tissue from elsewhere in the body are not equivalent to natural breasts in function or sensation, and reconstruction procedures are far from trivial. This flippancy towards physically healthy adolescents undergoing major surgery represents a total dereliction of responsibility. 

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The received wisdom that holds that detransition is neither common nor serious enough to call into question the practice of transitioning teenagers is based on little more than confident assertions. However, reliable and accurate figures regarding the rate of detransition are vital for the potential risks and benefits of transition to be communicated to patients and their families. Without this, informed consent is not possible. But far from being welcomed, attempts to address the knowledge gap on detransition often meet with intense resistance and accusations of transphobia or “weaponising” detranstioners’ experiences. In 2017, James Caspian, a graduate student at Bath Spa University, fell foul of this. His research proposal on detransition was rejected on the grounds that it could invite accusations of transphobia, directed not just towards Caspian himself but towards the institution.

In a recent issue of The Sociological Review, Rowan Hildebrand-Chupp, a graduate student at the University of California San Diego, argues that research into the causes and rate of detransition is “very methodologically difficult, expensive, and time-consuming” (what medical research is not?), and therefore a “waste of time and resources”, incompatible with supporting those who have detransitioned. It is strange to see in an academic journal the case being made for ignorance.

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Lack of curiosity and methodological rigour from the academic and medical worlds with regard to young female detransitioners has resulted in a paucity of evidence about the rates of, and reasons for, transition regret and reversal.

These data gaps appear almost to be actively maintained by those wishing to deflect scrutiny from what is looking increasingly like a medical scandal. For any other medical intervention of such gravity — especially one carried out in children — the occurrence of patients experiencing regret would certainly bring into question whether, balancing risk and benefit, the intervention was ethical.

When Deirdre McCloskey states that the experiences of detransitioners do not constitute “a sound reason to oppose gender change in children”, the question must be asked: what would constitute a sound reason? Apparently not the demonstrable fact that some individuals who transitioned as minors, or even as adults, go on to regret being left with sterility, loss of sexual function, and permanent body changes, in pursuit of psychological relief that proves temporary, or never comes at all.

What further extremity would have to be reached before doubt was cast in the minds of individuals such as McCloskey, or in the offices of Stonewall?

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