Transitioning Back to Maleness

Adherence to Gender Affirming Hormone Therapy in Transgender Adolescents and Adults: A Retrospective Cohort Study

CONTEXT

Transgender and gender diverse (TGD) individuals often seek gender-affirming hormone therapy (GAHT). While receipt of GAHT has been associated with improved well-being, the risk of GAHT discontinuation and its reasons are not well known.

OBJECTIVE

There were two main objectives: (1) To investigate the proportion of TGD individuals who discontinue therapy after an average of 4 years (maximum 19 years) since GAHT initiation; and (2) to explore reasons for GAHT discontinuation. This was a retrospective cohort study at academic centers providing care to TGD adolescents and adults. TGD individuals prescribed estradiol or testosterone between January 1, 2000, and January 1, 2019, were included. GAHT continuation was ascertained using a 2-phase process. In phase 1, Kaplan-Meier survival analyses were used to examine likelihood of GAHT discontinuation and compare discontinuation rates by age and sex assigned at birth. In phase 2, reasons for stopping GAHT were investigated by reviewing records and by contacting study participants who discontinued therapy. The main outcome measures were incidence and determinants of GAHT discontinuation.

RESULTS

Among 385 eligible participants, 231 (60%) were assigned male at birth and 154 (40%) were assigned female at birth. Less than one-third of participants (n = 121) initiated GAHT prior to their 18th birthday, constituting the pediatric cohort (mean age 15 years), and the remaining 264 were included in the adult cohort (mean age 32 years). In phase 1, 6 participants (1.6%) discontinued GAHT during follow-up, and of those only 2 discontinued GAHT permanently (phase 2).

CONCLUSION

GAHT discontinuation is uncommon when therapy follows Endocrine Society guidelines. Future research should include prospective studies with long-term follow-up of individuals receiving GAHT.

Transition Regret and Detransition: Meanings and Uncertainties

Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.

Some Limitations of "Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist's View"

There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating "gender-affirmative" model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for "eligible" youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.

Medical detransition following transgender identity reaffirmation: two case reports

Background Recently, increased social and scientific attention has been paid to gender detransition, a phenomenon in which individuals discontinue gender-affirming medical interventions (GAMI) aimed at alleviating gender dysphoria (GD). Yet, clinical knowledge of detransitioners and their experiences is still scarce. Case reports published in the literature suggest that both internal and external factors may influence this decision. Methods Two transgender individuals treated for GD at a gender identity unit presented with a desire to discontinue GAMI. A description of their clinical evolution is presented. Results Increased body satisfaction, self-esteem, self-acceptance, and self-empowerment with respect to their transgender identity were mentioned by the patients as reasons for discontinuing gender-affirming treatments. Coinciding factors included reduced GD, positive changes in social environments, better interpersonal functioning, and higher levels of psychological well-being in general. Conclusions Gender detransition is an under-researched phenomenon. These cases highlight the need for a more nuanced approach to gender-related clinical presentations, which involves providing individuals the opportunity to work on their social ecosystems and explore alternative options to manage GD before initiating GAMI.

Gender detransition: a case study

Within the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

The study's purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

Reflections on the Clinician's Role with Individuals Who Self-identify as Transgender

The fact that modern patterns of the treatment of trans individuals are not based on controlled or long-term comprehensive follow-up studies has allowed many ethical tensions to persist. These have been intensifying as the numbers of adolescent girls declare themselves to be trans, have gender dysphoria, or are "boys." This essay aims to assist clinicians in their initial approach to trans patients of any age. Gender identity is only one aspect of an individual's multifaceted identity. The contributions to the passionate positions in the trans culture debate are discussed along with the controversy over the official, not falsifiable, position that all gender identities are inherently normal. The essay posits that it is relevant and ethical to investigate the forces that may have propelled an individual to create and announce a new identity. Some of these biological, social, and psychological forces are enumerated. Using the adolescent patient as an example, a model for a comprehensive evaluation process and its goals are provided. The essay is framed within a developmental perspective.

A Typology of Gender Detransition and Its Implications for Healthcare Providers

Gender detransition is an emerging yet poorly understood phenomenon in our society. In the absence of research, clinicians and researchers have applied the concept of detransition differently, leading to inconsistencies in its use. The article suggests a typology of gender detransition based on the cessation or the continuation of a transgender identity to address this issue. Implications of this typology for healthcare providers are discussed, emphasizing the increasing necessity of developing clinical guidelines for detransitioners. Finally, the article reflects on the possibilities of preventing detransition, which underlines the challenges that clinicians face when treating individuals with gender dysphoria.

Debate: The pressing need for research and services for gender desisters/detransitioners

The number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well-being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, 'desisters', or to reverse their transition, 'detransitioners'. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters' experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow-up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning - confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.

Informed Consent for Transgendered Patients

The request of a transgendered-identified patient for psychiatric, medical, or surgical services creates ethical tensions in mental health professionals, primary care physicians, endocrinologists, and surgeons. These may be summarized as follows: Does the patient have a clear idea of the risks of the services that are being requested? Is the consent truly informed? While this question is starkly evident among cross-gender identified children contemplating puberty suppression and social gender transition and young adolescents with rapid-onset gender dysphoria, it is also relevant to young, middle-aged, and older adults requesting assistance. Many patients cannot tolerate detailed discussion of the risks. This article reviews the history of informed consent, presents the conflicts of ethical principles, and presents three categories of risk that must be appreciated before informed consent is accomplished. The risks involve biological, social, and psychological consequences. Four specific risks exist in each category. The World Professional Association for Transgender Health's Standards of Care recommend an informed consent process, which is at odds with its recommendation of providing hormones on demand. With the knowledge of these 12 risks and benefits of treatment, it is possible to organize the informed consent process by specialty, and for the specific services requested. As it now stands, in many settings informed consent is a perfunctory process creating the risk of uninformed consent.