Introduction to Detransition for Therapists

Detransitioners and desisters are a growing population that are in need of competent psychotherapeutic treatment. A detransitioner is someone who identified as transgender and took any medical steps toward transition, including taking puberty blockers, cross sex hormones, or having surgery, and then decided to reidentify with his or her natal sex. Reidentification may involve discontinuing cross sex hormones, changing gender presentation and/or having reversal surgeries.

A desister is someone who identified as trans but who reidentified with his or her natal sex before taking a medical pathway. Desisters who identified as trans may have undergone a social transition in which they changed names, pronouns, and presentations. Changes in presentation can also include use of binders to flatten the chest or packers to give the impression of male genitalia. Males may engage in tucking of their genitalia to make them less noticeable. Reidentification may involve changing back to using a birth name, for example.

Since approximately 2010, the numbers of children and young people identifying as transgender began a precipitous rise throughout the Western world. No one is sure exactly why such a rise occurred. Some posit that greater acceptability of transgender people encouraged those who might have remained closeted to come out. Others point to social factors that indicate that social contagion may be implicated in the rising numbers. In any case, many more children and young people have been seeking and receiving gender transition medical interventions. More recently, there have been a growing number of detransitioners and desisters writing and speaking about their experiences and seeking psychological help to deal with the aftermath of their gender transition. Although some return to the services or clinics who helped them transition, many find this difficult and so describe a sense that there are no professional services available to help them.

Destransitioners and desisters are an incredibly diverse group, and each person will present with his or her own individual story. Nonetheless, there are some themes that we are noticing in our work. This introduction to the topic is meant as a broad overview only, and necessarily can’t convey the full complexity of these clinical cases. Nevertheless, there are some common themes and needs we are becoming aware of in this population. 

Many detransitioners and desisters are young  

Anecdotally most of the detransitioners and desisters seeking therapy are between the ages of 15 and 34. Many of them became trans identified during their teen years or in their early twenties. An informal survey conducted online by a detransitioned woman in 2016 found that the average female detransitioner came out as trans at age 17, and the average age of detransition was 21. This means that many of them were negotiating a gender transition and detransition during a time in which they were also negotiating other significant developmental milestones related to identity and belonging.  

Many detransitioners and desisters are female 

As the numbers of young people seeking gender treatment soared, another trend was noticed. While most gender dysphoric children in the past were natal males, starting around 2010, there was a reversal in the sex ratio, with many more natal females identifying as trans. This trend has been observed throughout the West. No one understands exactly why this has happened. Correspondingly, many of the detransitioners and desisters coming forward are natal females. Anecdotally, it appears that natal males account for around 30% of detransitioners and desisters.  

Many detransitioners and desisters had complicated mental health needs before they transitioned 

There is considerable literature documenting the fact that many transgender young people have comorbid mental health conditions as well as neurodevelopmental conditions. It therefore is no surprise that the detransitioners and desisters seeking therapy often note that they were struggling with mental health issues at the time they became trans identified. This is significant for working with this population as most of the time, these mental health issues remain a concern after detransition. Issues that may have predated a trans identification include: social isolation, high functioning autism, giftedness, learning disabilities, depression, anxiety, obsessive-compulsive disorder and self-harm. Anecdotally, a number of detransitioners also have or have had body image difficulties and eating disorders. Mental health difficulties such as borderline personality disorder, bipolar disorder, or psychosis are also sometimes seen in this population. These issues often remained unaddressed during the gender transition and may reassert themselves after detransition.  

Many detransitioners and desisters are same-sex attracted

To date, the majority of the deisisted and detransitioned young people we have worked with now understand themselves to be gay or lesbian and now understand their transition to have been motivated in part by internalized societal homophobia.

Some detransitioners feel traumatized by transition 

This is certainly not the case for everyone: some detransitioners and desisters feel grateful for their gender exploration, they may appreciate the physical changes that resulted from taking cross sex hormones, or even surgeries, and feel that they were all necessary steps to have taken at the time. However, there are detransitioners who describe their transition as traumatizing in and of itself. Some of our patients describe feeling betrayed by the mental health and medical services that sanctioned their treatment, some feel that they have undergone a form of “medically assisted self-harm.”

They may feel deep regret and sadness about the loss of their natural speaking voice, their breasts, or other organs. In general, the more medical interventions a detransitioner has had, the more likely he or she is to feel traumatized. The experience of someone who socially transitioned but never had any medical intervention is different from someone who took testosterone and may have to deal with a permanently altered voice, a receding hairline or unwanted facial hair. Her experience will differ again from someone who took testosterone and also had a bilateral mastectomy, who may be dealing with grief about the loss of her breasts, as well as scarring and nerve damage. And this latter person will have a very different experience from the detransitioner who may have taken testosterone, had a mastectomy, as well as a hysterectomy and oophorectomy.

Likewise, natal males who had breast implants, an orchiectomy, vaginoplasty, or other surgery will likely have a very different experience from a male person who detransitioned after taking estrogen but before undergoing any surgeries.

Detransitioners who have had an orchiectomy or an oophorectomy will be dependent on synthetic hormones for the forseeable future. There are also additional possible health complications associated with having had a hysterectomy. It is important for therapists to understand that these interventions can be the source of deep regret and trauma for some, perhaps particularly at the earlier stages of detransition.  

Detransitioners and desisters are often isolated 

Many detransitioners and desisters felt as though they had a supportive community in which they achieved a deep sense of belonging when trans identified. They possibly lost this support, or at least aspects of it, when they began to detransition. Although detransitioners and desisters are finding each other online and developing new communities and networks, they may not know other detransitioners in person. In addition, many report that talking about their detransition publicly is sometimes difficult. Society has worked hard to respond to people coming out as trans, but does not yet have a script for those who have to come out again as detransitioning. Our patients have described an array of responses, including angry criticism, misunderstandings or minimisation, or statements that remind them that transition does work for others.

Some detransitioners and desisters feel alienated from their family of origin. There may have been conflict over their initial gender transition. The young person may feel somewhat embarrassed or ashamed and might be reluctant to share their detransition with parents. In some cases, the conflict with parents may have been so extreme that it damaged the relationship. On the other hand, some detransitioners whose parents were quick to affirm their trans identity and support their medical transition feel betrayed that no one tried to slow them down.  If parents affirmed them, funded medical interventions, or became activists, detransitioners may feel guilty about letting them down. 

Detransitioners and desisters may have educational or vocational issues 

Many detransitioners report that they had to take time off of school during their transition or detransition process. They may have difficulty re-engaging in school or finding employment. They may not have much in the way of financial resources, and for some their lives may be chaotic.

Detransitioners and desisters may be contending with unlearning previous beliefs 

Many detransitioners and desisters report that their trans identification was influenced by the belief that we all have an innate gender identity, and this can differ from and take precedence over our biology. Many detransitioners and desisters now reject this belief and find it difficult to interact with therapists who don’t understand how important it is to have reclaimed their birth sex and have rejected the notion of innate gender identity.  

In conclusion, this is a new population that is beginning to present for psychotherapeutic treatment. We are learning as we go, but our work can be informed by what we know about working with trauma, undue influence, identity exploration, sexuality, body dysmorphia, and other similar issues. We will need to remain open to learning more as our knowledge of this population and their varied experiences grows.