The provision of gender affirming medical treatment for transgender youth has been restricted in several countries. Much of the opposition to adolescent transgender care has been ideologically motivated and reflects a wider attempt to restrict the rights of the LGBTQ+ community (Hines, 2020; Kraschel et al., 2022; McLean, 2021). Nonetheless, some of the opposition has been couched as concern about the risk that transgender youth may later regret their decisions to transition medically. This concern has received considerable attention both in the healthcare literature and in the mainstream media, with frequent articles reporting stories about adolescents who received gender affirming medical treatment and subsequently retransitioned to their cisgender identities (Doward, 2020; Lathan, 2022; Richards et al., 2019; Singal, 2018).
However, much of what is reported about the regret rates for adolescent medical transition is not scientifically supported. While some adolescents who receive gender affirming medical treatment do subsequently retransition to their cisgender identities, there is a lot of misinformation about the risk of regret. This article summarises the current available evidence on transition regret in order to attain a more accurate understanding of the risk of regret in transgender adolescents who receive gender affirming medical treatment.
The concern about adolescent transition regret is largely influenced by studies on “desistence”, which is when a gender nonconforming child later returns to identifying as the gender assigned at birth. Early research suggested that the large majority of children who present with gender dysphoria later revert to their genders assigned at birth when they reach adolescence (Zucker and Bradley, 1995). Similar results were also reported by subsequent studies (Drummond et al., 2008; Wallien and Cohen-Kettenis, 2008).
However, significant methodological problems with these studies have been raised, which suggest that they cannot reliably support claims about regret rates for gender affirming medical treatment. Importantly, the studies examined the persistence of gender noncomformity in prepubertal children, which is a different thing from the stability of gender identity in peripubertal adolescents. Hence, data on gender nonconformity in prepubertal children cannot be used to draw conclusions about the outcomes of medical transition in peripubertal adolescents (Ashley, 2021).
Furthermore, the diagnostic criteria used by these “desistence” studies were based on the criteria in fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), which have been criticised as being overinclusive. Importantly, these criteria do not distinguish transgender identity from other kinds of gender nonconformity (Temple Newhook et al., 2018). Hence, the studies would have included children who do not consider themselves to be transgender, which would have resulted in a significant overestimate of the regret rate.
Accordingly, the results of “desistance” studies are a poor proxy for the regret rates for gender affirming medical treatment in transgender youth. Below, we shall see that the results of other studies with different methodologies support very different conclusions about adolescent transition regret.
As noted above, “desistance” studies do not adequately distinguish different kinds of gender nonconformity in children. However, when research focuses specifically on transgender identity in adolescents, the rates of retransition are substantially lower. A recent prospective study of 317 transgender adolescents found that five years after socially transitioning, 94% had maintained their male or female transgender identities, 3.5% had proceeded to identify as nonbinary, and only 2.5% had reverted to their previous cisgender identities (Olson et al., 2022). This indicates that gender identities are generally stable in peripubertal adolescents.
Clinical research also indicates that the regret rate for gender affirming medical treatment in transgender youth is very low. In an early study of 22 transgender people who received gender affirming medical treatment in adolescence, none of the participants in adulthood regretted the decisions to transition medically (Cohen-Kettenis and van Goozen, 1997). More recently, two studies found that 96.5% and 100% of transgender adolescents who had initiated puberty blockers were subsequently happy to proceed with hormone replacement therapy at a later stage (Brik et al., 2020; de Vries et al., 2011). A recent study of 720 transgender people who commenced hormone replacement therapy in adolescence also found that 98% of participants chose to continue gender affirming hormone treatment into adulthood (van der Loos et al., 2022).
The above evidence indicates that the risk of regret for gender affirming medical treatment in transgender youth is very low, with studies consistently yielding regret rates lower than 5%. Indeed, the risk of regret for gender affirming medical treatment appears to be substantially lower than for many other healthcare interventions, such as knee replacement surgery (Kahlenberg et al., 2018) and radical prostatectomy (Ratcliff et al., 2013), which are often in excess of 20%.
The concern about regret has been used to suggest that young people are not capable of consenting to gender affirming medical treatment because their gender identities are not yet fully formed (Lathan, 2022). However, the above research suggests that this claim is scientifically unsound. As shown by the aforementioned studies, gender identity is reasonably stable in adolescence and the overall risk of regret for adolescent medical transition is very low.
Furthermore, recent qualitative research has shown that transgender adolescents aged 14 to 18 readily demonstrated the relevant understandings and abilities that mark the capacity to consent to gender affirming hormone treatment (Clarke and Virani, 2022). As well as being able to understand the treatment, evaluate the risks and benefits, and make decisions that are consistent with their values, the research showed that transgender adolescents were able to reflect critically on their gender identities and their own responsibilities regarding their healthcare decisions. Therefore, the evidence shows that the decisions of transgender adolescents to transition medically are not impulsive or coerced by peer pressure, but generally result from thoughtful and extensive deliberation regarding their identities, values, and desires.
The best available evidence to date indicates that regret rates for gender affirming medical treatment in transgender youth are very low, with studies consistently reporting rates of less than 5%. As with any other medical risk, the potential risk of regret must be weighed against the harms of withholding treatment. The World Professional Association for Transgender Health (2022) note that “allowing irreversible puberty to progress in adolescents who experience gender incongruence is not a neutral act given that it may have immediate and lifelong harmful effects for the transgender young person”. Research has shown that withholding or delaying gender affirming medical treatment for transgender adolescents is associated with higher rates of mental illness and attempted suicide in transgender youth (Sorbara et al., 2020; Tan et al., 2022; Tordoff et al., 2022). Therefore, it is reasonable to conclude that the low risk of regret following gender affirming medical treatment in transgender youth is greatly outweighed by the substantial harms of withholding or delaying treatment.
The evidence also indicates that gender identity in adolescence is stable. Moreover, transgender adolescents are generally able to demonstrate the relevant understandings and abilities that comprise the capacity to consent to gender affirming hormone treatment. Therefore, young age is not a legitimate reason to deny one’s first-person authority over one’s own gender identity. Transgender adolescents are capable of making informed decisions about their own gender affirming care.
Of course, none of the above denies that some adolescents who receive gender affirming medical treatment change their minds. It is important to recognise that some adolescents do decide to retransition to their cisgender identities and that they should be fully supported with their decisions to do so. However, the above does indicate that the risk of regret is much lower than commonly assumed and is much lower than for many other medical interventions. When this is considered in the context of the substantial benefits of gender affirming medical treatment in the overwhelming majority of people, it can be concluded that the provision of gender affirming medical treatment for transgender adolescents is clinically and ethically justified