DETRANSITIONING

A few years ago, the headlines seemed to be crowded with stories about people on the forefront of the fight for transgender rights. Caitlyn Jenner on the cover of Vanity Fair, the battle in North Carolina over bathrooms, and Laverne Cox’s outspoken fight for trans rights, accompanied by her rise to stardom with her role on “Orange is the New Black.” More recently the Trump administration has taken steps to ban transgender people from military service.

But even as the transgender community has continued to emerge and slowly become more accepted by the general public, in recent years, a growing number of people who have changed gender have subsequently changed their mind and decided to “detransition” or “retransition,” reverting to their original gender. These reversals have fueled concerns about whether those who opt to undergo grueling social and medical transitions are adequately prepared to make the decision, and what psychological resources are available to them, as well as whether it’s necessary, in order to fully realize one’s identity, to identify with a gender at all.

“Transitioning is not a one-size-fits-all process or path,” said Julie Graham, SF Gender Health Director. “It’s different for each person. “Transition is not monolithic, it’s not prescribed, and we talk about it like it is,”. That’s part of the problem. According to the Human Rights Campaign, the largest American LGBTQ+ advocacy group, many Americans don’t personally know anyone who is transgender, and without that direct connection, the idea of transitioning is still unfamiliar.

Transitioning is a different experience and process for each person, but the basic steps are similar and can include a change in name and pronouns used, hormone replacement therapy (HRT), and/or sex reassignment surgery.

The decision to detransition or halt the transition process can stem from a range of reasons, Graham said. Of the many possibilities, Graham cites four primary reasons for a change to occur or to stop the medical transition process: people who got the sufficient amount of treatment, those who are forced to detransition by external forces, those who regret having transitioned medically without prior knowledge it wasn’t the right choice, and people who regret having transitioned medically and fully regret their choice.

Walt Heyer is part of a group of people within the trans community who regretted his decision to transition. Heyer subsequently launched a website and public speaking tour to share his story and draw attention and support for others in a similar situation.

As he has shared in USA TODAY and elsewhere, Heyer was four years old when he was cross-dressed by his grandmother. At seven years old, he was sexually abused by his uncle. This resulted in a severe amount of trauma and complex psychological issues that manifested into him thinking he wanted to be a woman.

The HRC calls “transgender” an “umbrella term for people whose gender identity is different from the sex they were assigned at birth.” According to the The Williams Institute at UCLA, that there are about 700,000 transgender adults in the U.S., making up about 0.3% of the general population.

Gender identity is a concept that refers to the gender one identifies with on the inside, regardless of one’s physical body. In the vast majority of people, their gender identity matches their biological gender – this would classify someone as cisgender, a term introduced in the early 1990s. This is not the case for people in the transgender community.

Gender dysphoria is a “condition in which individuals experience distress due to incongruence between their gender identity (or experienced/expressed gender) and the gender they were assigned at birth” (according to the Diagnostic and Statistical Manual of Mental Disorders [DSM-5], by the American Psychiatric Association). Heyer, because of his early childhood trauma, became “gender confused.”

His experience provides a window into what the steps to a gender transition may look like.

Heyer was married with two kids while he was working as an associate design engineer on the Apollo space missions. For decades he’d felt that his physical gender did not align with his self-perception. Finally, at age 40, Heyer went to San Francisco to see Dr. Paul Walker, who was the number-one expert at the time in the field. Walker was the first to lay out the Standards of Care, a guide to diagnoses of gender dysphoria and requirements for medical transitions for the trans community.

Dr. Walker diagnosed Heyer with “gender identity disorder” (now gender dysphoria). Heyer was then told he needed hormone therapy as a way to “cure what had happened to him,” according to Heyer. He then had “bottom surgery,” done by Dr. Stanley Biber, who was also an expert, and had performed over 4,000 of these surgeries – mostly male to female, according to the New York Times – in his lifetime.

A common gender transition surgery is a vaginoplasty, or a penile inversion procedure, where doctors will create a “vaginal vault” out of the penile skin. According to UCSF, the recovery period is about 6 weeks, and the patient is to refrain from using a bicycle or swimming for up to three months post operation.

In Heyer’s case, his “bottom surgery” cost about $8,000 out of pocket. When the surgery was complete, Heyer became Laura Jensen and moved to San Francisco to work for the FDIC and the US Postal Service. He then moved to Santa Cruz to attend UC Santa Cruz to study to become a counselor.

At its most basic level, there are some key steps to a transition process – some of which people may choose to take, depending on their preferences.

Transitioning can involve a name change, dressing differently (according to one’s true, inner gender), a change of pronouns (ex. from he/him/his to she/her/hers), hormone treatment and/or sex reassignment surgery. Not everyone who identifies as transgender decides to take hormones or undergo a surgical transition.

The World Professional Association for Transgender Health (WPATH) has a Standards of Care manual, which Dr. Walker helped create, that lays out, among other things, the measures that must be taken before the physical process of transitioning can begin. James Caspian, a British psychotherapist, expressed concern over the lack of prerequisites for a medical transition now: “Under Standards of Care in around about 2012, when the last issue was made, they removed the requirement for counseling from the treatment recommendation. So in other words, you could have treatment without having any counseling. Before that, before 2012, it recommended three months of counseling before you could have treatments.”

For hormone replacement therapy and gender reassignment surgery, an assessment is usually required by a mental health professional such as a therapist or a hormone provider who is qualified in the same field.

For most hormone treatments and surgeries, there are four criteria, according to WPATH's Standards of Care: “persistent, well documented gender dysphoria; capacity to make a fully informed decision and to consent for treatment; age of majority in a given country; and if significant medical or mental health concerns are present, they must be reasonably well-controlled.” Hormone therapy is not always necessarily a prerequisite for surgery but may often precede it. Caspian noted that the problem lies in the fourth listed item, where mental health issues are not often addressed properly: “We were seeing a massive rise in the numbers of young women, some of whom were in their teens coming and asking for sex reassignment treatments. And we're also noticing in that patient group, many of them had very complex mental health problems that have not necessarily been resolved.”

Dr. Andre Berger runs Rejuvalife Vitality Institute, a medical center in Beverly Hills which provides services like cosmetic surgery, liposuction, and anti-aging medicine. There, Dr. Berger also provides hormone replacement therapy for transgender patients.

For a female to male transition, Dr. Berger says the basic treatment is testosterone to increase “virilization” (masculine characteristics like body hair and a deeper voice). For a male to female transition, it’s just the opposite: a suppression of virilization and “effeminization” through estrogen.

Within a few weeks changes will start to occur, like buds underneath the nipples, a redistribution of fat around the body and the face beginning to take a more female shape. Hair growth around the body will slow down and thin out.

Berger’s treatment plan follows three steps: testing, initiation of treatment, and monitoring.

Berger says the most important thing is that the patient “consult with somebody who really does understand how to provide safe and effective treatment.” Berger’s center runs blood testing and tries to gauge the patient’s sense of well-being.

Berger said monitoring his transgender patients going through this process is steady for the first year, once every three months. After that point, it’s about every six months.

Estrogen treatment can be taken orally and topically. Testosterone can be given orally or through injection.

Berger emphasized the importance of mental health support throughout the process. "It's really not appropriate to start a patient on either hormonal transgender treatment or surgical treatment unless that patient is psychologically prepared."

There are some risks associated with hormone replacement therapy. For male to female transitions, testosterone can sometimes result in acne/oily skin, increased susceptibility to osteoporosis, and male pattern hair loss (balding), there’s also cardiovascular risk that must be monitored.

Berger says there are similar risks for those taking estrogen to transition: metabolic risks, again, osteoporosis risks, and other sources say there’s a slightly elevated risk for problems like blood clots, strokes and cancer.

Finally, Berger stressed that “the essence of success is a happy patient.” His mission at Rejuvalife is to give patients safe treatment and help them achieve their goals in the best possible way.

The first gender reassignment surgery was done at the Johns Hopkins University Hospital in 1965, and continues to be a common practice today. The WPATH Standards of Care says that “While many transsexual, transgender, and gender-nonconforming individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria.”

The Standards of Care also lays out some of the various procedures available for patients suffering from gender dysphoria. They split it up into three categories for each: breast/chest surgery, genital surgery, and other, more aesthetic surgical interventions.

For male-to-female patients, some of the surgeries included are augmentation mammoplasty (breast implants), penectomy (removal of the penis), orchiectomy (removal of testicles), vaginoplasty (creation of a vagina, as explained above), clitoroplasty, vulvoplasty. And finally, more aesthetically, there are procedures such as “facial feminization surgery, liposuction/ lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various [other] aesthetic procedures.”

For female to male patients, the same areas are targeted, but in reverse. Procedures include mastectomies, a creation of a male chest, hysterectomy (removal of the uterus), phalloplasty (construction of a penis), and “vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses.” For “nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures.”

Olson-Kennedy of the LA Gender Center prefers the term “retransitioning” because it denotes the idea of taking your life not in a reverse direction, but simply in a new or different one. Olson-Kennedy says that people who are not trans or who haven’t spent much time around trans people are quick to jump to thinking that retransitioning is solely due to regret or identity issues.

He estimates that over the last 26 years of the clinic’s history, less than a dozen people have decided to retransition or forego further changes to the way they express their gender identity.

However, Olson-Kennedy said, “people make different decisions around retransition because of struggles around employment, and discrimination, and violence, and rejection from family and rejection from religious communities… there are so many people who are making decisions around transition or retransitioning out of very practical, non identity-related, strategic decisions.”

Because there isn’t sufficient research done on the subject, there aren’t specific numbers as to how many people detransition, and/or how many do so due to regret their decision.

James Caspian, a British psychotherapist who worked at The London Gender Clinic, just north of Mayfair in central London, for 10 years, saw hundreds of patients and helped many successfully transition.

However, he also saw an emerging pattern – of those who were unhappy with their transition and wished to reverse back to their biological gender. This pattern intrigued him, to the point where he enrolled at Bath Spa University as a master’s student, where the curriculum was geared toward research of the student’s choice.

Caspian created a proposal to study detransitioning, but was denied by the university’s ethics committee. His research was deemed “too complex” for a master’s level degree. He sued in 2017, and is still in court proceedings over it.

While previous research shows that it’s a small group of people who seek detransition, Caspian’s own experience led him to want to learn more. Work by another clinician drew his attention with a finding that many patients (almost 90 percent) are “lost to follow up” after their transition, meaning that doctors never really know what occurs after, or if they are happy in their new body.

Caspian said in an interview: “But I was seeing it and I get it because I've seen it in my own practice, so I was really concerned, really, really concerned. By this time I'm thinking, my God, this is such important research. You know, there's something huge happening here and nobody's researched it.”

Claude R. (@__laudecay__ on Twitter) is a student at the University of Chicago studying math, physics and computer science. He's currently taking the year off to do cybersecurity engineering.

He felt as though he had doubts during his transition, which may not have been fully addressed by therapists. He also had "a lot of mental illness that was completely ignored," which included eating disorders, sexual abuse, violent homophobic bullyinh and trauma from parental abuse.

After one appointment with a "gender identity specialist," he had a letter for hormones and top surgery.

He said, "I'm so...angry, no lawyer would take my case, I was 19 and severely mentally ill and nobody wanted to help, all they wanted was money and/or woke points."

The reason Claude is working instead of in school this year is because of $30,000 worth of debt, which he said was accumulated because his surgen lied about his insurance. He now describes himself as "mutilated, hairy, deep voice, body only someone with a...fetish would be attracted to."

"It feels like a bad dream when I look in the mirror but I can't wake up from it."

For more examples of those who detransitioned or retransitioned, there are articles listed on the Peak Trans website, organizations/movements like the Pique Resilience Project or the Detransition Advocacy Network (who just had a conference in Manchester). There’s also a lot of discourse on the Reddit thread, r/detrans.

Mental health services & support

Olson-Kennedy of the LA Gender Center says he prioritizes providing mental health services throughout the process of transitioning, as a opposed to standardizing therapy as a prerequisite for a medical transition.

Mental health resources are important for people in the trans community to have access to throughout their transition, especially considering the relatively high number of suicide attempts that occur within the trans community, compared to their cisgender counterparts. A few years back, a British LGBTQ+ organization, PACE, partnered experts from three universities to create a study of a small group of youths titled “The RaRE Research Report: Risk and Resilience Explored.”

They found that the suicide attempt rates for young transgender people (48 percent) are almost double those of their cisgender counterparts (26 percent). The RaRE Report attributed this high rate to factors like a negative coming out experience, transphobic bullying, and struggles with their identity as trans in their family/with friends/in school.

The study noted participants felt the responses from medical/professional staff were inadequate, due to a lack of awareness and training.

The RaRE Report details the reasoning shared by “Maureen,” a trans woman who attempted suicide after being “raised in a hostile environment, bullied in her social circle, physically abused by her stepfather and reprimanded by her mother because of being trans.”

“Nobody to talk to, the community boxing you up, and they’re just not happy with you,” the report relayed from Maureen. “I couldn’t live my life….no you are not a girl, and you can’t live as a girl…I got very depressed with everything and then I saw the fast moving car,” Maureen continued. Then I saw another one straight after so I decided to jump underneath it.”

This is where resources like the LAGC come in. Olson-Kennedy says the majority of people at the LAGC are looking for therapy as they move through the transition process. “The first couple of years are probably the most challenging because you’re navigating a social/gender role transition,” Olson-Kennedy said. “Having a supportive, therapeutic space to process that can be really beneficial.”

LAGC offers peer and therapy support groups. This can be especially helpful for those who may be “isolated from other trans or non binary, non cisgender people.”

“Being able to come to a support group, whether that’s a social or therapy support group,” Olson-Kennedy said, fosters the ability to “be in a space with other trans or non binary non cisgender people, where people can collectively talk about their experiences.”

One example he cited was a patient/client he saw at the St. John Well Child and Family Center, where he used to run a medical program. Someone came in who was assigned male at birth and had transitioned about five years prior to seeing Olson-Kennedy. They came in wanting to retransition.

Olson-Kennedy asked his patient/client, “Do you feel as though something has shifted or changed as it relates to your gender identity?”

The patient/client responded, “Oh my god, absolutely not. I absolutely am a woman, but I am an identifiable trans woman, which means that I get harassed, that I can’t find a job, and it means that my family won’t speak to me, and it means that I lost connection to my church community, and if I present myself as a boy, even if it’s a feminine boy, I get all of that back.”

Olson-Kennedy said it's a familiar story. “Many of those people that I know who’ve tried to live in their assigned birth gender ultimately come back to reengaging in transition related services," he said." Because it’s actually difficult to be successful in your life when you are not experiencing yourself in an authentic manner.”

It’s important to understand that this idea of retransitioning is a “continuation” of a journey or a process, as described by Olson-Kennedy. Yes, there are some like Walt Heyer who wish to detransition. And then there are others, like Dax Joubert-Bousson, who perhaps don’t identify with either gender, and take hormones just until they feel comfortable. The medical process doesn’t have to be binary.

Joubert-Bousson is a 21-year-old trans/non binary college student living in Washington State who uses the pronouns “they, their, theirs”).

Joubert-Bousson took to Twitter regarding the idea of detransitioning, saying, “The stigma around detransitioning is dumb ‘cause not only does it invalidate people who decide they don’t like HRT, but it also makes non binary people who decide they don’t want everything HRT offers look bad.”

In a follow up interview, Joubert-Bousson said that there’s often a nuance that exists because people experience gender dysphoria. It’s not necessarily binary – meaning not restricted to just being or becoming female or male: “A lot of medical care for trans people is very binary, like a lot of people in the trans community see transitioning as a binary thing."

Joubert-Bousson was talking to their doctor, whom they call “wonderful” because she “doesn’t have that binary view of the world.” She told them, “If you wanted to, you could only take hormones up until the changes you want, and then you can stop. Then you can go off hormones and then just live your life, you know?”

They say, “I feel like people should just realize that transitioning is not this black and white thing we’ve made it to be," Joubert-Bousson said, "It doesn’t always have to be that.”