Over the holiday season I had the pleasure of finally reading the national bestseller, Detransition, Baby. On the surface, the story depicts the complex relationships between Reese, a transgender woman who strongly desires a family, her ex-wife, Ames – a transgender woman who detransitioned to live as a cisgender man – and Ames’ cisgender female partner, who is unexpectedly pregnant with his child. The story delves much deeper than the relationships between these characters, as it exceptionally articulates many of the emotional intricacies of the transgender experience and addresses one of the most taboo topics in the transgender community – detransitioning and regret.
The terms “transition” and “detransition” have fallen out of favor in the vernacular of the transgender population as they incorrectly imply that gender identity is contingent upon gender-affirmation processes.1,2 More importantly, the terms “detransition” and regret are not synonymous. Conflating these terms has undermined the intrinsic nature of gender identity, which has resulted in political and legal consequences seeking to limit or outright ban care for transgender patients.
Dr. K. Ashley Brandt
As a gender-affirming surgeon, one of the most common questions I get asked is the rate of regret patients have after their surgeries. While I have no issue answering the question when it is presented, I do not hesitate to point out some of the problematic subtext inherent in such inquiries. Within the line of questioning, many often comment, “It’s so permanent,” “I can’t believe people can do this to their bodies,” or “How sure are patients before undergoing these surgeries?” While these comments and queries can be downright offensive, they seem to stem from the difficulty people have comprehending gender dysphoria and the painstaking steps people take to affirm their identity. The implication of these comments also reveals a more deep-seated issue – general distrust of individual bodily autonomy, personal identity, and choice.
For the obstetrician-gynecologist, understanding the concept of autonomous, patient-centered decision-making should be second nature, as we face a similar line of interrogation when discussing abortion, contraception, and pregnancy. No other field faces this level of scrutiny when it comes to defending a patient’s bodily autonomy. For example, given the history of reproductive injustice with tubal ligation procedures, the American College of Obstetricians and Gynecologists has issued clear guidelines regarding counseling of women while acknowledging the tenuous history of these procedures with minority subgroups. According to their committee opinion, ethical counseling for such a permanent procedure involves understanding the content of information presented to the patient, how that information is conveyed, and self-reflection on the part of the provider.3 The approach to counseling and understanding gender-affirming care is no different.
I want to be clear that regret after gender-affirming surgery is rare, occurring in 0%-3.8% of patients.4-6 In a separate study, 91% of patients expressed significant improvement in quality of life after surgery.7 However, what is disheartening about patients who experience surgical regret is that it originates from continued difficulty from the transition process itself and ongoing discrimination – even though the patient’s physical characteristics match their gender identity.4-6 Similarly, in another survey which examined 17,151 participants who had pursued gender affirmation (broadly defined), approximately 2,242 (13.1%) reported a history of detransition.2 Among these adults, the vast majority (82.5%), cited external factors such as school harassment, sexual violence, family pressure, and social stigma as reasons for detransitioning.2 Other associated factors included male sex assigned at birth, nonbinary gender identity, bisexual orientation, and having an unsupportive family.2
When Ames is explaining his “detransition” to his cisfemale partner, he states: “I got sick of living as trans …[sic]… I am trans, but I don’t need to do trans.”8 While there is still more research needed to further understand detransitioning and surgical regret, these few studies demonstrate a heart-breaking reality – in many aspects of our society it is still extremely difficult to live as a transgender person.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She did not report any disclosures.
References
1. National LGBTQIA+ Health Education Center, A program of the Fenway Institute: LGBTQIA+ glossary of terms for health care teams. 2020. Available at www.lgbtqiahealtheducation.org/wp-content/uploads/2020/10/Glossary-2020.08.30.pdf. Accessed Dec. 30, 2021.
2. Turban JL et al. LGBT Health 2021;8(4):273-80.
3. Sterilization of women: Ethical issues and considerations. Committee Opinion No. 695. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e109-16.
4. Ruppin U, Pfafflin F. Arch Sex Behav. 2015;44:1321-9.
5. Lawrence AA. Arch Sex Behav. 2003;32:299-315.
6. Landen M et al. Acta Psychiatr Scand. 1998;97:284-9.
7. Papdopulos NA et al. J Sex Med. 2017;14(5):721-30.
8. Peters T. Detransition, Baby. New York: Penguin Random House, 2021.