“Trans Regret” Isn’t Real
(Photo by Volkan Olmez on Unsplash)
Raise your hand if, when you have told another person (friend, parent, doctor, therapist, etc) that you wanted to get a gender affirming medical intervention, they told you that you might regret it. Bonus points if they brought up some other “person they know” who got a gender affirming medical procedure and then had to get it reversed at great expense, and/or deeply regretted it, etc.
This is a really common refrain, and I’m certainly not the only person who has pointed it out. In fact, the idea that people who seek affirming medical interventions (like hormones and surgery) will regret it and that this is something to fear and fret about and potentially a reason to avoid giving people medical interventions has been used to create medical policy for over sixty years, animate multiple academic and medical studies, and to deny an untold number of trans people life saving care…which can and has resulted in pain, suffering, and death for many trans people.
However, the research that has been done on gender affirming surgeries has shown an astonishingly low amount of regret. For reference, total knee replacements have a regret rate of 6-30%. A recent meta-analysis of the research on trans regret showed an overall rate of regret that was less that 1%. Now obviously these numbers are not 0. There is no action that anyone can take in life that has a 0% rate of regret. But there is a difference between the regret that some people feel after seeking trans surgeries, and the tool of Trans Regret, which is used to control and dehumanize trans people.
Lets break it down.
Capital-T Capital-R Trans Regret
So when I use Trans Regret, capital T capital R, to refer to a phenomenon in this article, that means I am talking about a very specific thing. It does not mean I am referring to folks who regretting the medical interventions they received. Rather, I am referring to this idea, generally spread about by cis people and especially doctors, that trans people are at great risk for seeking medical services that they do not need, that if people obtain these services when they do not need them, it will cause a major disruption of their life and mental health, that this disruption is so dangerous and so overwhelming that it must be avoided at all costs, and that the proper way to control and curb these instances is to use a gatekeeping system where doctors and mental health providers must confirm an individuals trans identity in order to allow them to access gender affirming procedures.
This is not real.
And by that, I mean that it was created by mid-century doctors and researchers as a trauma response and is not reflective of the lived realities of trans people. However, due to the imbalance of power between trans people and their medical providers, this concept has had an outsized impact on nearly every trans person who has ever sought medical intervention or legal name and gender changes. One of the ways that the specter of trans regret has controlled trans people’s lives is through medical gatekeeping. In practice, this has included a many-headed hydra of transphobic policy has looked like:
Scare tactics
Requiring one, two, or even three letters for folks to access surgeries and hormones
Refusing surgeries and hormones to individuals who the provider did not think would pass well
Refusing surgeries and hormones based on race and radicalized beauty/“passing” standards
Refusing surgeries and hormones based on sexuality and sexual expression
Refusing surgeries and hormones for any other capricious reason the provider felt like offering
Denial of non-binary identities (and refusing medical options for non-binary identified folks)
Requiring people to follow a one-size-fits-all medical approach (and therefore, paradoxically, requiring people to obtain procedures they didn’t want to access privileges they needed)
Making the requirements to obtain affirming care so ludicrously difficult that such care was available only to white, wealthy, thin people and even then, they were often denied.
Laws and policies that prevent trans people from obtaining care at all
Laws and policies that prevent gender affirming care to be covered by insurance
The current push to deny care to trans adolescents and children
The current push to deny trans children the opportunity to participate in sports
The recent push for “bathroom bills” especially in schools and especially where adolescents are involved
The list could go on and on, but I wanted to publish this blog at some point so I will stop there. Given these negative outcomes, all of which continue to cause many negative health and life outcomes for trans people, I couldn’t help but wonder where the fear of regret and the subsequent gatekeeping came from…so I started looking.
The History of the Specter of Trans Regret
I have researched medical gatekeeping of gender affirming care as part of my dissertation. What I found were articles where Benjamin outlined his opinions about when and how what we currently call gender-affirming care should be provided. He often made shadowy references to regret, but these were never backed up with citations or explanations, even in medical journals that were well-respected. Consider this quote from the Journal of Sex Research (1969):
“Throughout the years of my interest in transexual (sic) patients, two nightmares have plagued me, when it came to surgery. If the operation was denied or made impossible for whatever reason, medical or economic, self-mutilation or suicide could be the consequence. Both, unfortunately, have occurred. The other nightmare was and is the fear that the operation might later be regretted. That, too, has happened. Actually, there was hardly ever admission to that effect, but that means little.” (Emphasis mine)
I know from reading other articles of the time that there were many documented cases of suicide and self-mutilation among folks who were denied treatment. Benjamin himself says here that he is merely speculating that cases of regret exist, yet his entire system of gatekeeping is predicated on the idea that they must exist, and people simply aren’t telling him about them. (A great resource on this topic is this article, “Barred From Transition: The Gatekeeping of Gender Affirming Care during the Gender Clinic Era” by Aaron Wiegand)
In addition to this puzzling quote, I also found articles that explained that Benjamin had very little, if any, love for psychology and psychologists. So why was Benjamin so afraid of regret, and why did he create standards of care that explicitly required endocrinologists and surgeons to obtain letters of support from psychologists before providing affirming care to patients, creating a system where he and others would be working directly with psychologists? I struggled to find answers to these questions until I found the phone number for a person who worked with Harry Benjamin. I asked this person my question, and they told me that Harry Benjamin was worried about regret due to a patient of his who did express regrets, and then died by suicide. My understanding is that this event was so traumatic to Harry and to those who worked with him that it created this idea and culture of fearing regret.
To be clear, this is obviously a tragedy and a trauma. It is a tragedy that many trans people, myself included, can deeply relate to, since so many of us have lost loved ones by suicide. In fact, the greatest tragedy of all of this is the staggering number of trans folks who have died by suicide because affirming care was gatekept from them. I am not trying to compare one person’s life to another, but it is incredibly painful to me that these doctors didn’t think about how the issue here was not a trans person’s capacity to know what kind of care they needed and wanted, but rather, structural and social transphobia that likely made their patient’s lives impossible. It is also deeply sad that this one death was taken so much more seriously in the policy than the many, many, many trans deaths that have occurred as a direct result of medical gatekeeping.
How Trans Regret has Been Deployed Since
Perhaps one of the most conspicuous markers of Trans Regret in trans medical policy has been the persistence of the mental health provider’s letter, and how it has been used to control who has access to hormones, surgery, and legal name and gender change (and therefore, accurate legal identification documents, which in turn control and moderate one’s access to general society). That (long) sentence may be a little overwhelming—to be clear, this is the topic I chose to write my dissertation on, so its a little hard for me not to slip into academic jargon speak around this!—but lets unpack it.
There’s a massive history here, and I am sure I will write more about it as I process my research. But for most trans people, any medical or legal situation that required confirming their trans identity has included obtaining and presenting a letter from a mental health professional that documents that they have “gender identity disorder” or have a documented and verified history of “gender dysphoria.” The vocabulary and assumptions have changed over the years, but what this means in practice is that if a person wanted correct identification documents, hormones, or surgery, they were required to get a mental health practitioner to essentially validate their identity as trans.
Even when “gender identity disorder” was removed from the DSM (the book psychologists and psychiatrists use to diagnose mental illness), and even when all the major and respected medical associations released documentation that trans identity was not a mental illness, this requirement has persisted. The most intense versions of this policy have required that the documentation come from a doctoral-level mental health professional, when the majority of therapists are trained at the master’s degree level. These policies often require multiple letters as well.
When the World Professional Association for Transgender Health (WPATH) has been pressured on this point, they have often fallen back on the idea that the very low instance of trans regret is because the gatekeeping requirements, and/or have countered with the idea that gender affirmation medicine can’t be provided “on demand.” But the published evidence on this letter paints another picture. Rather than being a benign or positive force, the letter and other gatekeeping methods have resulted in a variety of negative outcomes fro trans people, including:
A lack of medically necessary care, resulting in negative health outcomes including illness and death
A lack of insurance coverage for medically necessary care
Increasingly capricious standards among insurance companies, who will often (arbitrarily) require 2 or even 3 separate medical letters for a single gender affirming procedure
An inability to access accurate, updated identification documents, resulting in danger up to and including physical assault and death for trans people
A hostile or imbalanced relationship with mental health providers, who could be an important source of support for trans people
And more.
Shifting Goalposts for Gender Affirming Treatment
What’s most baffling about this requirement is how the goalposts move around whenever it is convenient for the powers that be, but when trans academics, medical professionals, mental health professionals, researchers, and activists (and our allies) try to shift the goalposts, its like they were anchored into the very crust of the earth!
For example, even thought these guidelines were set forth based on the idea that trans people might have regrets, or potentially based on a trauma response, they have persisted in the face of actual peer-reviewed scientific evidence that they are harmful. And although it seems as if the world of gender affirming medicine is moving away from the gatekeeping models, the gatekeeping persists in new and exciting ways.
A great example of this is the hate comment I received on a three-minute tiktok I made on this topic. The commenter claimed that I was ignoring the “deception of thousands of teenage girls.” When I told this commenter that they were in fact the one who had been deceived, they left a flurry of comments culminating in the charge that I was being paid by “Big Pharma” for spreading unethical information.
Listen, I will admit, I had a great laugh over this. I screenshotted the comment and showed it to my friends and spent the evening chuckling over the idea. But it wasn’t lost on me that this comment and the deranged illogic beneath it was pulled directly from the TERF playbook of disinformation. Further, this is exactly the kind of disinformation that is being used to gatekeep care from both minors and trans adults. The evidence for providing care, and the evidence that informed consent works well and results in very minimal regret is robust and easily verified. But the ongoing cultural war has always found trans folks to be highly effective political footballs, and the specter of Trans Regret is one of their favorite talking points. (For more information on this point, please see TransLash’s amazing The Anti-Transgender Hate Machine podcast).
Essentially, trans people and the folks who actually listen to trans people have known for some time now that Trans Regret is a myth, a talking point, and a tool used by bad actors. But somehow its a lot harder to make your voice heard when you’re arguing that trans people are capable of making choices for themselves. If you’re a person who doubts that trans people have the wherewithal to make medical choices for themselves, you need to spend some time getting familiar with your internalized transphobia.
So How Do We Approach Regret?
You may be thinking, “But like, some people DO regret their transitions, right?”
And you would be right. There are people who have regret about hormones and surgery, there are folks who have regrets about their social transitions and legal transitions. There are folks who detransition and there are folks who retranslation and there are folks in some area between all of these descriptors. Human beings are vast, we contain multitudes, and our experiences span the gamut. When something as varied and messy as gender comes into the mix, there are no impossible outcomes.
This topic deserves just as much careful consideration as the false narrative of Trans Regret, and as you may have noticed in this post, these topics are deeply intertwined. In my next post, I will talk about regrets, how to think about them, how to deal with them, and how to address fear and anxiety around them.
Stay tuned, and I love you.