“It’s Just Such a Big Decision”: What Our Fears About Detransition Are Really About
Written September 28, 2023 by Jess Romeo, PMHNP-BC
Public discourse about access to gender-affirming care has evolved rapidly in just the past 10 years. As more trans and nonbinary Americans share their stories, a political debate has emerged. And as with many political debates, thoughtful and nuanced conversations have given way to fear-based talking points. While activists and organizations fight to defend access to gender-affirming care, lawmakers and politicians who oppose gender-affirming care are fixated on detransition and regret. They fear that an adolescent will identify as transgender, take hormones, perhaps have a surgery, and then realize later that decision wasn’t right for them.
Let me be clear—a sharp focus on detransition and regret almost always reveals an inherent skepticism about the validity of trans identities. The most revealing trait I’ve seen in this debate is when one appears incredibly informed about all the negatives (like risks and irreversibilities of hormone therapy), has gathered stories from well-mined fringe sources to back up statements about regret, negative outcomes, and detransition, and yet remains thoroughly unconvinced when shown overwhelming data on suicide rates and mental health outcomes for trans youth.
We know that access to gender-affirming care significantly reduces mental health symptoms such as depression, anxiety, and suicidal ideation. We also know that laws restricting access to care have negative effects on the mental health of trans youth. Trans adolescents and young adults face nearly double the risk for suicide compared with cisgender young people.
Ignoring this data is reckless.
The focus on detransition and regret is also misplaced. Detransition is rare. And as a trans psychiatric nurse practitioner and clinical social worker who works primarily with trans and nonbinary patients, I can tell you that there is so much more to trans identity than medical procedures (and the lack thereof).
Discussing gender diversity solely in terms of access to medical treatments echoes outdated dialogues that reduce our identities to body parts – and ultimately misses the point.
So I think it’s important to ground this discussion with two important truths underlying our society’s fears about detransition.
Truth No. 1: Our concern about trans kids one day regretting their decision is the lowest-hanging signifier for societal anxieties about progressive causes “taking things too far.”
I understand why this fear of regret is so pervasive. Adolescent brains aren’t fully developed. And most of us would cringe at some of the awful decisions we made as adolescents. It’s easy to shudder and wonder that if we were offered the opportunity to change our gender back then, would we have done so – solely in response to feelings of depression, social isolation, or struggles with identity in general?
I mean, I might’ve. But I’m trans, so I’m the wrong person to ask…
But the reality is that gender-affirming care is not something adolescents can access on a whim.
It’s a gradual, thoughtful process. The informed consent models for treatment dictate the thorough discussion of treatments’ risks and benefits, as well as the relative reversibility and irreversibility of certain treatments.
Nonmedical gender affirmation comes first. Then treatments with the most reversibility are offered. The risks they carry are managed by established monitoring protocols. And surgeries are dead last, requiring the highest threshold of medical necessity – as well as age requirements of either 16 or 18 years old, depending on the procedure, the insurance company, and where a patient is located.
Additionally, developmental concerns are taken into account by the providers who do this work day in and day out. Pediatricians, pediatric endocrinologists, pediatric NPs and PAs, and mental health providers who work with adolescents are well aware of this. The WPATH Standards of Care also recognize that this developmental period is unique, and developmental concerns should be accounted for in the informed consent process. So the concern that providers are taking advantage of an inherently transient time in identity development to push an agenda is simply unfounded.
Truth No. 2: Our anxiety about detransition and regret in adolescence is deeply rooted in our own internal biases about gender, sexuality and our definition of normalcy.
Through family and other social groups, formal education and pop culture, we all learn and internalize what is “normal.” And under that classification system in the U.S. today, cisgender identities – gender identities that align with the sex someone is assigned at birth – are normal. Transgender or nonbinary identities are not.
That means our society tends to perceive an adult who detransitioned or had regrets about medical gender-affirming care as a tragic figure. They were normal all along, and now they don’t get to be anymore.
This normative bias also comes through in discussions about hormone therapy and infertility. Many adults express concern about trans kids not being able to have biological children after having hormone treatment.
Our fear of this infertility risk is rooted in the idea that wanting to have biological children is a normal preference shared by the majority of people. And that losing this option – and regretting a decision you made in adolescence that cost you that option – is inherently tragic.
We in turn overemphasize the value or importance of “a normal life,” which may not align with what people actually want. We are doing little more than projecting our own fears about social transgression onto trans kids.
Expanding the Parameters of Normal
But what if, instead of reacting with fear, we embraced gender diversity?
What if we valued or normalized gender identities other than male or female just as much as we value and normalize cisgender identities? What would our world look like?
It’s hard to imagine. But if we could broaden our perspective on the richness and beauty of gender diversity, we could consider detransition and regret differently.
We could stop reflexively worrying about detransition and regret because we wouldn’t consider it as such a perceived loss.
We could more easily center the principles that should guide these decisions—namely, bodily autonomy and freedom of self-expression.
In a society that celebrated, accepted (or even tolerated) gender diversity, gender-expansive adolescents seeking authentic self-expression and belonging might be able to spend more time exploring their gender identity before having medical interventions. Gender identity and body characteristics could be untangled from one another, and we could more easily honor the beautiful fluidity and diversity of gender that is a naturally-occurring variable trait in all humans.
If we could expand our definition of normal identities and choices…
Shed our collective fears about change…
Recognize our internalized norms and not project them onto others…
We could shove tired old templates aside in favor of something new.
In so doing, we could create a world where trans kids can thrive – where all of us can thrive.
Jess Romeo (he/they) is a psychiatric nurse practitioner, clinical social worker, and trans-identified clinician in the DC metro area.
He specializes in psychiatric care of trans communities, and educates clinicians and professionals on providing evidence-based gender-affirming care.
