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Claims of 'Low Regret' Exposed as Flawed—True Detransition Rates Remain Unknown

The Detransition Rate Is Unknown

detransitionpuberty suppressionmedical ethicsgender dysphoriasystematic reviewsurgeriesgender-affirming care
Authors
J. Cohn
Year
2023
Journal
Archives of Sexual Behavior

Methodological Limitations

  • The author is affiliated with the Society for Evidence-Based Gender Medicine (SEGM), an organization known for opposing gender-affirming care for minors, which represents a potential conflict of interest that is not fully disclosed in the conflict of interest statement ('The author has not disclosed any competing interests').
  • The paper selectively critiques studies showing low regret/detransition rates while citing and relying heavily on convenience samples of detransitioners (Littman, 2021; Vandenbussche, 2022) that have their own significant methodological limitations including self-selection bias, online recruitment, and lack of representativeness.
  • The paper uses observed regret/detransition times from Table 1 (ranging 3.2-130 months) to argue for minimum 8-year follow-up, but this threshold appears arbitrarily chosen toward the upper end of the range and is applied uniformly across different interventions (social transition, hormones, surgery) that likely have different temporal dynamics.
  • The 'worst-case scenario' analysis for loss to follow-up assumes all lost patients regretted/detransitioned, which is an extreme and likely unrealistic assumption that would systematically overestimate true rates.
  • The paper critiques Turban et al. (2021) for requiring participants to still identify as transgender/non-binary, but fails to acknowledge that this study explicitly examined temporary detransition rather than permanent detransition, conflating different research questions.
  • The comparison to depression research (TADS study) is potentially misleading because depression has been studied for decades longer than gender-affirming care, and the author does not acknowledge that the ethical and practical barriers to RCTs in gender-affirming care differ substantially from depression.
  • The paper cites Clayton (2023) regarding placebo effects in gender-affirming care without noting that this is a 'Letter to the Editor' presenting a hypothesis rather than empirical evidence, giving it unwarranted evidentiary weight.
  • The author claims that 'the true discontinuation, detransition, or regret rates are not known' but simultaneously presents extensive arguments suggesting these rates are likely higher than commonly reported, creating tension between the stated agnostic position and the argumentative structure.
  • The paper does not apply its own critical framework equally to studies it cites favorably; for example, Littman (2021) and Vandenbussche (2022) convenience samples of detransitioners have severe selection biases (only including those who identify as detransitioners and are active in online communities) that are not subjected to the same scrutiny as studies showing low regret rates.
  • The funding statement indicates open-access charges were paid by SEGM, the author's affiliated organization, raising questions about editorial independence and whether the paper's framing aligns with SEGM's known advocacy position against gender-affirming care for youth.

Key Findings

  • The true rates of detransition, regret, and discontinuation of gender-affirming medical interventions are unknown, despite frequent claims that they are very low (0.3-0.6%).
  • Existing studies on regret and detransition suffer from serious methodological flaws: too-short follow-up periods, high loss to follow-up, inadequate measurement instruments, and samples that don't represent today's patient population.
  • Observed times to regret or detransition are often long—averaging 3-10+ years—meaning studies with short follow-up periods systematically underestimate true rates.
  • The current evidence base for medical interventions for gender dysphoria is of 'low' to 'very low' quality, with no randomized controlled trials comparable to those standard in other fields like depression treatment.
  • Young people and families considering medical intervention should be informed that reliable data on risks like regret and detransition are unavailable, as this uncertainty is essential for truly informed consent.

Abstract

The author, J. Cohn, argues that reliable rates of detransition, regret, and discontinuation of gender-affirming medical interventions are currently unknown. While extremely low regret rates (e.g., 0.3–0.6%) are frequently cited in medical literature and the press, Cohn contends that these figures come from studies with serious methodological flaws—particularly insufficient follow-up time, high loss to follow-up, vague or inappropriate definitions of "regret" and "detransition," and samples that are not representative of the rapidly growing contemporary population of adolescents with gender dysphoria. The paper outlines four key requirements for credible outcome research (adequate follow-up duration, minimal loss to follow-up, appropriate measurement instruments, and relevant sampling) and demonstrates that most frequently quoted studies fail one or more of these criteria. The author concludes that until better long-term studies are conducted, the true rates of regret and detransition remain uncertain, and this uncertainty should be communicated to patients and families as part of informed consent.

Summary

This paper argues that reliable rates of detransition, regret, and discontinuation of gender-affirming medical interventions are currently unknown, despite frequently cited low percentages in medical literature and media. The author identifies four key methodological requirements for valid outcome studies—adequate follow-up time, minimal loss to follow-up, appropriate measurement instruments, and relevant sample populations—and demonstrates that existing studies fail to meet one or more of these criteria, making their reported rates unreliable for informing clinical decisions or patient consent.

Conclusion

The detransition rate is unknown. Existing studies claiming low regret or detransition rates (0.3-0.6%) are unreliable due to methodological flaws including: insufficient follow-up time (often shorter than observed median times to regret of 7.5-8 years), high loss to follow-up, inappropriate measurement instruments, and non-representative samples that differ from current patient populations. The frequently quoted extremely low rates are based on studies with adults who underwent extensive screening under older protocols, not the current adolescent-onset cohort with different characteristics. Until properly designed long-term studies are conducted with adequate follow-up duration, small loss to follow-up, appropriate definitions and measurement tools, and relevant samples, the true rates of discontinuation, detransition, and regret cannot be determined. This uncertainty should be communicated to patients and families as part of informed consent for gender-affirming medical interventions.