Medical transition by trans people, its prevalence and demographics, and rates of regret of treatment are perennial subjects of public curiosity and media controversy. With unfortunate frequency, this has taken the form of scaremongering that depicts the growing numbers of trans people presenting for treatment as an almost literal epidemic: the British press now routinely resorts to baseless alarmism and conspiracy theories characterizing the rise in trans youth as resulting from nefarious efforts at “tricking” cis youth into believing they’re trans, a transparent relabeling of the ugly accusations of recruitment leveled at the gay community in decades past. Accompanying such fears are predictions of mass waves of regret to follow, as large numbers of supposedly misdiagnosed individuals come to realize they were cisgender after all.
While emotions run high on these issues, relevant facts are typically in short supply. A recent study of trans people in the Netherlands provides a sober corrective to this wild speculation. Wiepjes et al. (2018) studied a group of 6,793 trans people who were evaluated at the largest Dutch gender identity clinic from 1972 to 2015, tracking how many went on to receive hormone therapy and gonadectomy (orchiectomy or vaginoplasty for trans women, and hysterectomy with oophorectomy for trans men), as well as how many reported regret.
Unsurprisingly, the number of trans people seeking treatment has grown substantially over time, with the authors reporting that the number assessed per year “increased 20-fold from 34 in 1980 to 686 in 2015.” Those raising the alarm about the rising numbers of trans youth seeking treatment should consider that this is simply a continuation of a long-term trend in treatment of gender dysphoria, rather than the result of an entirely new phenomenon or causative factor. Notably, the median age of adults evaluated has decreased substantially since 2008:
However, the proportion of those evaluated who go on to receive medical transition treatment has decreased over time: 90% of adults evaluated in 1980 went on to receive HRT within five years, compared to only 65% in 2010. The authors suggest that increasing availability over time of information on the possibility of transitioning “could have led to referrals of people with milder forms of GD and people who were not sure of their feelings and just wanted to explore these with a psychologist.” Contrary to media reports characterizing gender clinics as “fast-tracking” their clients into medical transition, it’s clearly far from guaranteed that those who are evaluated will go on to pursue or receive any medical treatment at all.
Because this clinic also evaluates children and adolescents, data was available to address the common misconception that all adolescents (aged 12-18 years in this study) who receive puberty blockers will invariably go on to pursue further medical transition. This was far from the case: 4.1% of trans girls, and 0.7% of trans boys, stopped taking puberty blockers without receiving HRT or any further medical treatment. Additionally, of the children (aged under 12 years) who were evaluated, only 40.3% went on to receive puberty blockers.
Rates of regret of transition were also calculated, and 0.5% of those who underwent gonadectomy reported experiencing regret, lower than the 2.2% rate of regret found among transgender Swedes from 1960-2010 (Dhejne et al., 2014). Unlike many other studies, the authors further examined the reasons for regret:
Reasons for regret were divided into social regret, true regret, or feeling non-binary. Transwomen who were classified as having social regret still identified as women, but reported reasons such as “ignored by surroundings” or “the loss of relatives is a large sacrifice” for returning to the male role. People who were classified as having true regret reported that they thought gender-affirming treatment would be a “solution” for, for example, homosexuality or personal acceptance, but, in retrospect, regretted the diagnosis and treatment.
Out of the 14 identified cases of regret, 7 reported true regret as defined by the authors, while 5 experienced regret due to social factors such as lack of acceptance, and 2 reported regret due to being nonbinary. Of the 14 cases, 10 underwent one or more reversal surgeries.
The results of this comprehensive study reveal a distinctly different picture than that which is commonly presented in media and popular discourse:
- The number of trans people receiving treatment has recently increased – but it has also been increasing for the past several decades.
- Referral to a gender clinic for evaluation does not automatically lead to medical transition; for a substantial and growing proportion of this group, transitioning is never initiated.
- Gender-dysphoric adolescents who receive puberty blockers do not universally go on to receive further transition treatment: a small number will discontinue blockers without pursuing transition.
- Regret after surgical transition is rare, occurring in about 1 in 200 people in this study – and when regret does occur, this is often due to external social factors such as discrimination and stigma.
What we see here is not a worrisome phenomenon of overdiagnosis and accompanying mass regret, but rather increased access to treatment and appropriate evaluation that has minimized the risk of unnecessary treatment. This is neither frightening nor an epidemic – it is the healthcare system working appropriately in addressing a condition that is receiving growing awareness. ■
