How The Supreme Court Should Think about Detransition
The court needs to keep in mind that all medical treatments have risks, benefits, and side effects.
Our culture wars around gender-affirming medical care for minors have reached a fever pitch. Half of U.S. states have banned medical treatments for adolescent gender dysphoria – a diagnosis indicating that one is experiencing clinically significant distress and impairment in functioning from their physical body not being in alignment with their gender identity. Banned medications include estrogen, testosterone, and puberty blockers. The bans have been challenged in federal courts around the nation, and appellate courts have come to divergent opinions regarding whether they are constitutional. Tomorrow, the U.S. Supreme Court will hear oral arguments on whether these laws can stand.
One topic is sure to take center stage in their discussion: detransition. Ban proponents argue that some people will start these medications then later stop them. In their brief, Tennessee argues nothing short of a ban can deal with the problem of detransition. The Supreme Court ought to approach that assertion with a great deal of skepticism. It should also think about detransition with the delicate nuance the topic deserves.
First of all, we need to remember that medicine is a field of probabilities, not certainties. When a doctor prescribes a medication, they work with a family to discuss potential risks, potential benefits, and potential side effects. Gender-affirming care is not unique in this regard. For example, doctors routinely prescribe the cholesterol-lowering medication Lipitor because it usually prevents strokes and heart attacks. However, it can also sometimes cause muscle breakdown that can destroy the kidneys. Patients and doctors weigh these risks and benefits to decide what the right treatment is for them and their values. All treatments come with a regret rate (knee replacements come in at around 17%), and gender-affirming medical care is not unique in this regard.
Second, proponents of these bans have misrepresented how common such regret is. You will commonly hear ban proponents claim there has been a “wave of detransition” experiences. They provide no convincing data. A recent study published in JAMA Pediatrics followed 220 young people who received gender-affirming medical interventions during adolescence. Only 4% expressed regret, and only half of those 4% actually stopped the medication, suggesting that these regrets were complex and also came along with perceived benefits sufficient to continue the medication.
We can always pick apart research studies. Some may argue that the teens in this JAMA Pediatrics study are the right kids to receive treatment,1 and that other kids (say those who don’t realize they are trans until later in adolescence) may have higher regret rates. If this were truly the concern, Tennessee (the state in question in the upcoming Supreme Court case) would have banned care only for those who had later-onset gender dysphoria. They did not – they passed an overly broad law that banned care for all kids, including kids like these who benefit. You’ll also hear ban proponents say that they worry some adolescents are receiving gender-affirming medical interventions without the mental health evaluations recommended under current guidelines. Once again, if this were the case, Tennessee could have passed a law requiring these mental health evaluations be done prior to care being initiated. Other states like West Virginia have taken this approach. Tennessee did not. Furthermore, doctors are already regulated when it comes to breaking from medical guidelines – through malpractice suits and medical board sanctions that existed before Tennessee’s law.
The court also needs to recognize that detransition experiences are complex and heterogeneous. As a pediatric psychiatrist and director of the Gender Psychiatry Program at UCSF, I’ve spent a great deal of time thinking about de-transition. I’m one of the few to publish about it in the peer-reviewed academic literature. I encourage the justices to understand de-transition as much more complex than waking up one day and realizing out of nowhere that you are cisgender. A framework that considers internal factors (from oneself) and external factors (from one’s environment) is essential for understanding de-transition experiences with appropriate nuance.
In one kind of situation, de-transition can be from external factors like harassment and stigma. The experience is common among transgender people. In 2021, our research team published a study in which we asked over 17,000 adult transgender people if they had ever de-transitioned (i.e., gone back to living as their sex assigned at birth) at some point in their lives. 13% had. The vast majority explained their detransition was due to at least one external factor. They cited reasons like pressure from parents, societal stigma, and worries about getting a job. Quotes included, “I live in a very conservative place and was afraid for my safety” and “school staff harassed and abused me daily for my gender expression.”
Ban proponents will cite some studies showing that as many as 30% of people who start gender-affirming hormones stop them. They’ll misleadingly imply that those people are now cisgender and regret their treatments. But the studies they cite provide no indication of why people stopped their hormones, or whether or not they are still transgender. People may stop hormones for any number of reasons: losing their insurance, feeling satisfied with the physical effects they’ve achieved, or feeling that it’s just too hard to deal with the stigma of presenting to the world as transgender. The court needs to examine cited studies closely to avoid having the wool pulled over their eyes.
It’s also possible that de-transition could come from an internal factor, or a person’s evolving understanding of themselves. While research suggests that identifying as cisgender after starting gender-affirming medical care is rare, it seems that it does sometimes happen. The largest published study of people who de-transitioned medically identified 100 people from around the world. Some in that study said they de-transitioned because they came to believe their initial trans identity was a result of trauma, internalized misogyny, internalized homophobia, or another mental health problem. Of important note, the mean age of starting transition for people in this study was 22 years, so they likely did not transition in the pediatric model of care, which requires a comprehensive mental health evaluation. As I’ve explained elsewhere, such evaluations should include discussion of these topics prior to starting medical interventions to ensure families are getting all the information needed to make the right decision for their adolescent. Experiences in the study were diverse – some felt gender-affirming care was still a good experience, some regretted it, and some still identified as transgender or non-binary.
To make things even more complicated, we know from minority stress theory that external factors can become internal factors. For example, if you join a community of people constantly telling you that your transgender identity is from trauma, you may start to internalize and believe this, even if it isn’t true. This was very much the situation with the “ex-gay” movement of the past. Many of those individuals later came out as still being gay, after a period of saying they had been “cured” of their homosexuality.
We have started to hear similar things may be happening among “de-transition movements.” In recent court filings regarding one high-profile person who identifies as a detransitioner, who has close ties to Marjorie Taylor Greene, it was reported that her de-transition began with an LSD trip in which she believed the holy spirit was speaking through her and telling her that she was “living a lie,” suggesting a religious driver of her detransition. She later posted on social media that she “believe[s] the answer to the Gen Z identity crisis is Jesus Christ and Christian principles.”
For people who are de-transitioning, it’s vital they’re offered support and essential that this support include an open space to discuss what de-transition means to them and the drivers of it. Exploring internal and external factors, as well as how external factors can drive internal factors, is important.
But when it comes to this court case, the complexities of de-transition cannot be overlooked. De-transition simply isn’t a valid justification for states to ban medical care. If that were truly their goal, they would have passed a law putting in safeguards to ensure rigorous treatment guidelines are followed. Instead, they banned care across the board. The justices need to treat this area of medicine like any other. No medical interventions offer a 100% success rate. All medical decisions involve weighing risks, benefits, and potential side effects. Physicians, families, and adolescents are in the best position to make these medical decisions, not state lawmakers – which is part of why all major medical organizations oppose bans on gender-affirming medical care. De-transition is an important topic to reflect on and understand, but it is not a rationale for banning treatments that help many people who pursue them. And it’s not a topic for which it’s appropriate to gloss over nuance.
Of note, our team recently published a study showing that it’s not unusual for adult transgender people to not have realized they were transgender until after the onset of puberty, arguing against this notion. That being said, the latest guidelines from the World Professional Association for Transgender Health do not that one may extend the diagnostic process adolescence with a lack of prepubertal gender incongruence.