“It’s Just Such a Big Decision”: What Our Fears About Trans Adolescents & Detransition Are Really About
The opinions in this essay solely represent those of its author, Jess Romeo (he/they)—a board-certified psychiatric-mental health nurse practitioner, clinical social worker, and transgender man.
He provides comprehensive training & mentorship to clinicians & practices who want to provide trans-affirming care. Go here for more information.
The debate over trans-affirming medical care for adolescents is roiling, and I imagine the election cycle of 2024 will only further stoke flames on both the left and right.
Given that it’s likely to become more, and not less frequently talked about in the media, I thought I might weigh in with a few thoughts on the problems with the debate itself, what our fears about trans adolescents detransitioning are REALLY about, and why they say more about us than anything else. I’ll also argue why a more inclusive perspective on gender would help us navigate this issue more wisely.
Photo credit: Alex Milan Tracy
First, the facts as they exist in September 2023 as of the writing of this essay:
We’re talking primarily about de-transition and regret here—the concern that an adolescent will identify as transgender, take hormones, perhaps have a surgery, and then realize later that wasn’t right for them.
First of all, de-transition is rare, but an increasing area of research as more people have access to gender-affirming medical care. Basic logic would suggest that as more people have access to the care, more people are likely to eventually regret having done so, or want to take steps to reverse their decisions. Some would argue this is perhaps especially true as care has moved towards an informed consent model and further from models that require extensive psychological evaluation prior to seeking gender-affirming medical care. I’m not entirely sure about that, and more importantly, I think that would reintroduce some antequated, harmful paradigms of care back into the equation.
To be clear, I am fully in support of an informed consent model vs. the previous models that placed mental health providers in the position of gatekeeping access to care. I also am not convinced of the fact that those previous models would adequately reduce the incidence of detransition, as many detransitioners cite diagnoses of depression, anxiety, PTSD, ADHD, autism, personality disorders, and history of sexual trauma as confounding factors that led to confusion about gender dysphoria. As a psychiatric professional who works with this population on a daily basis, I can tell you those diagnoses aren’t rule-outs for co-occurring gender dysphoria. They occur in many trans people who continue to identify as trans long after they take concrete steps to transition. And what we DO know is 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 are at nearly double the risk for suicide compared with cisgender young people, and ignoring or pushing aside this data is reckless.
Centre for suicide prevention, accessed 3 September 2023 at https://www.suicideinfo.ca/local_resource/transgender-people-suicide/
There are a number of nuanced articles that have addressed the topic, and we’ll learn more as the years progress and adolescents grow to adulthood. Unfortunately, I find this is a difficult, and charged issue to talk about since public discourse about trans issues, and access to gender-affirming care has evolved rapidly in just the past 10 years. The resulting dynamic from such rapid change, combined with active battles to defend access to gender-affirming care, has left little room for nuance in the conversation. Just look at any available online discussion about the topic, and you’ll see how difficult it is to thread the needle of a wise opinion that considers all the facts at hand.
In any socially charged conversation lacking nuance, the two sides come to the table with pre-existing beliefs, and overwhelmingly look for data that confirms those beliefs.
Those in my camp point to low detransition rates of 1% or less in existing data, cite that primary reasons for detransition involve external forces pressuring individuals to present publicly as one’s sex assigned at birth, and emphasize the mental health benefits of access to gender-affirming care as I just did. To be perfectly clear, those are incredibly valid, accurate, and important points.
And—I also think the drive to defend the necessity and efficacy of gender-affirming medical care for adolescents can lead some on my side to understate the irreversibility of some medical transition interventions, the complexity involved in medical informed consent, or the potential for regret or detransition. I don’t think that’s representative of the majority of people—it applies mostly to those who work less closely with trans/gender-expansive people, or who have less training on the specifics of medical gender-affirming treatments. I also think its consequences are minor, existing largely in the realm of failing to craft a precise and effective rhetoric to persuade skeptics, more so than in the quality and thoughtfulness of care that’s actually provided to trans adolescents.
I can also imagine that due to the intensity of the political climate, detransitioners DO feel left out or abandoned from the discussion, and suddenly devoid of community upon their difficult decisions. However, that’s certainly not true for all detransitioners. Many prefer to avoid speaking out because they don’t want their stories to be used as a tool for restricting access to care for others. To be honest, that’s an area I know less about—not because I’d prefer not to consider it, but because we simply don’t have much updated data in the past few years other than anecdotal reports of increasing numbers of people identifying as detransitioners on online communities. That’s certainly not nothing, and I hope we continue to learn more. But I have one major caveat here when we talk about our fears about trans adolescents & detransition:
Approaching this topic with a primary focus on detransition and regret almost always reveals an inherent skepticism about the validity of trans identities.
This isn’t just my opinion either. Those who express the most concern about detransition are much more likely to OVERstate risks involved with gender-affirming treatments, UNDERstate the psychological damage of restricting access to gender-affirming care, and demonstrate an inability to be swayed by facts to the contrary. I think the most revealing trait I’ve seen in this dynamic is when one appears incredibly informed about all the negatives like risks and irreversibilities of hormone therapy, has gathered receipts from well-mined sources to back up statements about regret, negative outcomes, and detransition, and yet—
Remains thoroughly unconvinced or claims “more research is needed for me to decide” when shown the overwhelming data on suicide rates and mental health outcomes for trans youth.
This tells me a lot about where you’ve chosen to seek information, and who you’ve chosen to trust (hint: it’s not trans people).
I believe this is a far, far worse error to make, and is one that is—at best—based in fear, reactivity, and a pre-existing skepticism about other types of social progress. At worst, it signals regressive beliefs that trans people are misguided, mentally ill, or morally inferior—and that we’re free to mutilate ourselves however we like—once we turn 18 and are entirely responsible for those poor decisions.
There is no easy way to navigate these conversations.
Ultimately, your pre-existing beliefs about the issue will dictate where you think the system should be calibrated for sensitivity vs. specificity. The same is true for many other social issues—those who are inherently mistrustful of people who use government benefit programs like food stamps, WIC, or SSI would like to see higher thresholds for entry to reduce the incidence of fraud. Those of us who aren’t concerned with this, and believe in the importance of these resources being accessible are comfortable with lower thresholds for entry.
I’m comfortable going on record to say that I believe it’s in the interest of the greater good to have a lower threshold for entry when it comes to gender-affirming care for adolescents, because I think its benefits far outweigh the potential consequences. But—and this is the reason for this post in the first place—discussing gender diversity by only talking about 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 a couple of important truths about what our fears about detransition are really about.
Truth Number 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.”
It’s just SUCH an easy target. And I understand why. Most of us would look back on some of the choices we made as adolescents and cringe at the awful decisions we ever-so-boldly made. It’s simple to shudder and think 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.
The truth is that once you get past that initial reaction and explore the facts of how this care is provided, you realize that gender-affirming care for adolescents is overwhelmingly given in an incredibly stepwise, thoughtful manner. The informed consent models for treatment dictate the thorough discussion of treatments’ risks and benefits, as well as the relative reversibility/irreversibility of certain treatments. If you want to learn more, feel free to consider some continuing education & support here.
Treatments with the most reversibility are typically offered first, 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 you’re located.
Right-wing pundits who discuss yell into microphones about this issue also present arguments like "“But their brains aren’t even fully developed yet"!” —as if the healthcare providers who work with trans adolescents have somehow forgotten everything they ever learned about adolescents.
Not a news flash—thanks.
Developmental concerns specific to that period are taken into account by the providers who do this work day in and day out. Adolescents DO start to have a heightened identification with peers, begin to explore their identities further outside their initial families of origin, and tend to have a sense of urgency driven by a brain fully primed for reward but not for long-term consequences. This isn’t news to pediatricians, pediatric endocrinologists, pediatric NPs and PAs, or mental health providers who work with adolescents. And in case they somehow HAVE forgotten (they haven’t), it’s written into the WPATH Standards of Care that this developmental period is unique, and that those particular concerns should be accounted for in the informed consent process.
In my experience working with trans adolescents in Maryland, DC, and Massachusetts—all states with relatively progressive laws and informed consent models for treatment (arguably places where it would be “easy” to get gender-affirming care and then regret it)—I haven’t worked with a provider or family that was cavalier about the role of the adolescent brain in transgender identity development, or who advocated for rushed treatment without proper assessment.
Children aren’t being offered surgeries as a first-line intervention, hormone treatments with irreversible effects aren’t a glib decision, and this care is overwhelmingly thoughtful, evidence-based, and life-saving.
Truth Number 2: Our anxiety about detransition and regret in adolescence is deeply rooted in internal biases about gender, sexuality, and what normal is.
What do I mean by this? Well, from where I’m sitting in the United States in 2023, I have an internal classification system inside me that says:
Transgender = not typical/normal
Nonbinary identities = not typical/normal
Gender matching the sex you were assigned at birth = typical/normal
If that’s my involuntarily-installed internal classification system, then I’m going to perceive an adult who detransitioned or had regrets about medical gender-affirming care as an incredibly tragic, unfortunate thing—i.e., they were normal all along, and now they don’t get to be anymore. Oh no- a “normal” kid could fall into this trap and regret it later because now they don’t look normal.
It’s important to note that this normative bias is also running the show when the idea of infertility comes up in discussion about hormone therapy. Many adults express concern about trans kids not being able to have biological children after having hormone treatment. To be clear, the facts are not that all gender-affirming hormone treatment renders trans adolescents unable to have biological children. But it is complicated, and fertility considerations are an aspect of informed consent. It’s possible that the decision to take hormones could result in future infertility.
But—our fear of adolescents making this choice for themselves is rooted in the idea that wanting to have biological children is a normal, default preference shared by the majority of people.
Furthermore, this idea would suggest that the loss of this option—and god forbid—regret for having chosen something in adolescence that took this option from you, represents something inherently tragic.
We, in turn, overemphasize the value or importance of “a normal life”, which might not align with what people actually want. We are doing little more than projecting our own fears about social transgression onto them.
But back to gender now. Here’s a thought to ponder.
What if having a gender identity other than male/female was just as valued, or just as normal as being a cisgender person?
It’s strange for me to propose, because I both 100% agree with this perspective and try to live my life by it, but also when I zoom out to think about a society that actually holds this value, it’s hard to imagine. My cultural conditioning is pretty strong here. BUT—if you can imagine that, and can broaden your perspective on the richness and beauty of gender diversity, a couple of key changes occur with regard to how you view transition regret & de-transition in adolescents.
a) Your reflex to be worried about de-transition and regret would reduce, because you wouldn’t consider it as such a perceived loss.
b) In a society that celebrated, accepted (or let’s face it, 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.
Let that one sink in for a minute.
If the social pressure to perform masculinity or femininity, or even present with physical characteristics of maleness or femaleness—were reduced, adolescents might not feel as though medical interventions need to happen as quickly.
If you REALLY want to get deep into this, we could talk about the existence of gender diverse people throughout history in communities with exactly zero access to medical treatment for transition. Many of these communities had accepted social roles, and even revered the gender expansive among them. Throughout history, it was outsiders to these communities seeking power who encountered these gender diverse people as an affront to their “superior” values. They used their existence as a means of arguing inherent superiority over them, justifying dehumanization, subjugation, and genocidal action. Before colonizers, the idea of strict gender roles was far less accepted as the template for the “correct” way to be. I go over this in great detail in my mentorship program, so people have a deep context for today’s conversations about gender & gender-affirming care.
But that is how it went, and as members of a society founded by colonizers, and the recipients of history written by the victors, adherence to the gender binary as evidence of superior status and worth is what we’ve inherited.
So…
While detransition as a result of regret is incredibly rare, a change of perspective to celebrate nonbinary, non-conforming, and unique gender expression would expand our ideas of what is normal, would de-platform binary gender expression as the default mode of humanity, and thus create the conditions for it to become even more rare.
Of course, there are exceptions to every rule, and medical transition measures are an important part of this discussion, though I don’t think they should be the primary focus for trans equity and autonomy.
Cases do exist of people who have regretted medical transition, and taken steps to reverse those changes. There are trans people who want to have biological children and struggle to weigh their need for gender congruence with the future ability to have biological children (I was one of them, by the way). Adolescents may want to start hormone therapy at a pace that seems quick from an outside perspective because of a long-suppressed and strong internal incongruence vs. externally-applied pressure—so increased freedom to explore gender sans medical intervention may not be liberating for them.
But in my view, the fact remains that OUR internal biases about what normal is make up the lion’s share of what drives our fear, our reactivity, and our concern about detransition, and the long-term well-being of trans adolescents. We project our own conditioning—our internal concepts of gender, our fears (traumas, maybe?) about not conforming, not being normal, not being accepted, and even our values about marriage, family, and children.
As a result, we end up speaking too loudly for a group of people struggling to be heard themselves, navigating an already difficult period in life (how much would someone have to pay YOU to relive middle & high school?), and tack on additional barriers to their well-being based on our internal prejudices.
And we do all of this under the guise of well-intended, sober-minded concern.
Summary & Conclusion
All in all, I know this is a complicated topic that will remain at the forefront of political debates for some time in the near future.
I unequivocally support measures and policies that allow gender expansive adolescents to make informed decisions about their medical treatment in conjunction with standards of care, and knowledgeable and thoughtful medical providers.
I also unequivocally denounce positions that disproportionately center the issue of detransition when engaging in this discussion, as they are almost always anti-trans sentiment masquerading as something else, and rarely offer opportunity for substantive and balanced dialogue (though they tend to claim they’re the only ones actually doing so).
Concern about medical transition being “such a big decision” for adolescents to make, and fears about trans adolescents detransitioning in the future are really about little more than our internalized cisheteronormativity, our vulnerability to inflammatory rhetoric, and a tendency to project our internalized norms onto these adolescents. By naming it, we can take away its power and have the tools to shove these templates aside in favor of something new, and that’s what I propose we do.
Honestly, I gotta say…it’s pretty nice over here with these old templates about gender and normalcy pushed over to the side. A bit easier to breathe…there’s a nice breeze.
Come join me, won’t you?
Jess Romeo (he/they) is a proud trans man, psychiatric nurse practitioner, and clinical social worker. He has a private practice in Maryland/Washington, DC and works to help other service providers improve their skills and competencies in working with LGBTQIA+ clients.
Read more about their training and mentorship programs for clinicians & practices here.
