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How listening to detransitioners can help improve gender-related healthcare services for all

by Stefan, a GETA member. Stefan’s substack can be found here.

Detransitioners have the dubious honour of being a minority within a minority. Trans people make up only about 1-2% of the general population in countries like Canada — the most recent census identified approximately 300,000 trans-Canadians. Within trans communities, detransitioners make up an as-yet-unknown but presumably small number. Rates vary. Some studies report detransitioners to be 1-2% of transitioners; other studies find detransition rates as high as 30%. Because they are small in number, the temptation can be to dismiss their stories and concerns. I believe that is wrongheaded.

Why listen to detransitioners?

While they may be a minority among transitioners, those who have transitioned and then detransitioned can help us better understand a condition of which we still know very little. Gender dysphoria is a complex condition with many different hypotheses undergirding it and relatively little hard data. By listening to the stories of detransitioners, we can start to better understand when medical interventions such as hormone treatments and surgeries prove helpful… and when they do not. Clearly, for some people, these interventions help. Though the exact reason they help is uncertain. For others, these interventions do not help and the consequences can be devastating. Given the significant physical and social risks of these medical procedures, detransitioners can help us fill in the gaps so that our interventions are responsive to the needs of everyone.

To improve care, we have a duty to listen carefully to everyone’s stories — especially those for whom existing treatments did not work. For example, if someone with a headache were to go to see their doctor, the doctor would not immediately jump to giving that person anti-migraine medication without first doing an assessment to find out if what they were experiencing was indeed a migraine. Lots of different causes for headaches exist — could be that the patient is dehydrated, or that they have a tumour, or that they bumped their head against something or got punched. Depending on the context of the headache, the healthcare provider will be able to develop a treatment plan that addresses their specific circumstance. Giving someone a glass of water is unlikely to cure their headache if dehydration is not the cause of it. And helping someone who was punched is only partly effective if the person doing the punching isn’t addressed too.

Gender dysphoria is unfortunately a bit more difficult to understand and treat than a headache because it is not a solely physical pain — for many, it resides primarily in the mind. Some people, for example, experience gender dysphoria as a social dysphoria, of not being perceived or related to in the way they see themselves. For others, it is primarily connected to their body and how they feel about the body parts they have. For some, it may be a combination of both. We do not know if medical interventions are equally effective for treating social dysphoria or physical/body dysphoria. And we cannot know that until we study those who have gone through the process, within their various social contexts.

Detransitioners give us a window into the reasons why people may not benefit from medical interventions, which can better equip clinicians to be aware of patterns and warning signs when working with clients at the start of these interventions. If we can prevent gender dysphoria from worsening, or could even develop non-invasive interventions that help clients move forward happily with their lives, without any unnecessary surgeries or hormone treatments, is that not a good thing?

Do gender dysphoric clients need mental health assessments?

Some advocates have expressed fear that acknowledging the existence of detransitioners or the existence of transition regret risks undermining access to trans-related healthcare services for the many who could benefit from these services. This is a legitimate fear — as attested to by the many bans being legislated across the USA. However, silencing people’s stories is not the answer — it cannot be. Detransitioners don’t disappear just because we don’t listen to them. Even if only one person expressed transition regret, they still deserve to have their story heard and learned from. The opposite is true too — if no one benefited from hormones and surgery and then someone came along for whom it did meet their needs, we would want to study that person to better understand why it worked for them. Listening to detransitioners speak is not about undermining care; instead it is about improving it — for everyone. People deserve care, but they also deserve proper care. And we can only provide good care if we take a close look at all the possible outcomes, including the ones that ask us to consider uncomfortable questions.

Some scholars have argued that we should do away with mental health assessments for gender dysphoric clients since assessments cannot accurately distinguish between those who will benefit from their transition and those who will not. But that is not the only reason for doing assessments. Rather than hindering care, comprehensive assessments allow us to build a therapeutic relationship with the client in order to deliver more individually-informed care that takes into consideration the client’s particular circumstances. We may not be able to tell for sure if medical care will benefit them, but through a relationship of trust, we can create a context within which regardless of what they decide to do, they will feel heard and supported — and well-informed of the benefits, the risks, and the unknowns of the path they are taking. A single, rubber-stamping assessment appointment doesn’t allow for this.

Rather than doing away with assessments, we should be working to improve clinical trust between clients and their clinicians. Assessors are not the enemy — they are there to help safeguard a very difficult path. Even when there are no co-occurring conditions to worry about, gender transition is an absorbing, challenging process.

How we conceptualize gender dysphoria matters in this process. I.e. if a clinician thinks of it as distress caused mainly by social discrimination or as the result of people not recognizing the client for who they are, then any mental health intervention would feel pathologizing and part of the problem (i.e. discriminatory). If, on the other hand, the clinician conceptualizes gender dysphoria as a condition that has different levels of severity, many paths into it and many different paths out of it, then they might be a bit more careful about how to treat it.

Gender dysphoria shows up differently for different people. To treat each instance as the same is a disservice to the client. Interventions must involve thoughtful, individualized deliberation.

The role of the therapist

The alliance between the client and the therapist is the most important ingredient in successful psychotherapy; this is equally — if not more so — true in the case of treating gender dysphoria. Therapists need a clear understanding of their role. If the therapist sees the client/therapist relationship as a collaborative one that is aimed at supporting the client’s life goals, then the gender affirming model makes a kind of sense on the surface. After all, the therapist is removing barriers for the client to self-actualize. But one could also argue that simply affirming a client’s gender identity without examining its origins and development over time, is a quick fix — a way just to get the client what they want in the short term. It also prevents the client from actually doing the necessary exploration to better understand the motivations underlying their decisions in order to ensure that when they get what they say they want they are well-informed and secure in their choices.

When we are given the power to be gatekeepers for medical interventions, we therapists are put in a very difficult position and we run the risk of muddying the waters of the therapeutic relationship. How can we be neutral third parties providing a space for exploration if we are implicated in facilitating a preferred outcome?

My own case demonstrates some of the risks of this quick-fix process. I was assessed and diagnosed in one 90-minute appointment. I was not interrogated about sexual dysfunction or neurodivergence. I was barely asked about my history of social isolation, self-harming, rumination, or eating disorders. I was not questioned about cultural/religious influences and how they shaped my understanding of my sexuality and identity. No potential link was drawn between these experiences and my gender dysphoria. At the end of the hour, I was referred to an endocrinologist as if it were the most natural next step in the world. The psychiatrist recommended that I consider continuing therapy but it wasn’t a requirement nor much of an expectation. Unsurprisingly, I didn’t continue. Once I had my diagnosis, the implied message was that when I started hormones and surgery all my other problems would go away on their own. The other implied message I walked away with was that hormones and surgery were not a big deal. But they are. They have a life-long impact on well-being. They can have serious side effects and complications. They require access to ongoing competent medical care. None of this was thoroughly discussed.

My experience is not everyone’s experience. But enough people have had this experience for me to know that it is not unusual. To acknowledge these gaps is not to deny anyone access to care. It’s the opposite. We cannot improve care if we do not acknowledge the gaps. That is what I am calling for. Access to care isn’t enough. Access to appropriate care is the goal.

What detransitioners can teach us about delivering good healthcare

Detransitioners have important stories to tell about where their care failed them and what we can do to help others who might find themselves in the same boat in the future. They can also help us better understand how gender dysphoria shows up in our practices as clinicians — if you’ve met one person impacted by gender dysphoria, you’ve met one person impacted by gender dysphoria.

While past gatekeeping practices were often humiliating, lengthy, and stigmatizing, some practitioners have responded by attempting to remove all safeguards and speed clients along a medical pathway. I used to believe this was a good approach, but I’ve evolved my view since then. I’ve seen too many people hurt to believe it is responsible healthcare.

What if removing safeguards isn’t the problem we should be focusing on? What if a more salient issue is in making safeguarding steps, such as screening for co-occurring mental health conditions like autism, more easily accessible? What if we prioritized treating the entire human, and seeing their gender for what it is — one sliver of the whole person that they are?

That is an approach that would benefit transitioners and detransitioners alike.

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