No Protocols Exist for Detransitioners: Clinical Leaders Call for Urgent Research and Services
The pressing need for research and services for gender desisters/detransitioners
- Authors
- Butler, C. & Hutchinson, A.
- Year
- 2020
Methodological Limitations
- The paper is a narrative review without systematic methodology: No explicit search strategy, inclusion/exclusion criteria, or quality assessment of included studies is described, making the evidence synthesis potentially selective and non-reproducible.
- No ethical approval was obtained despite discussing sensitive clinical populations: The 'Ethical information' section states 'No ethical approval was required for this article,' yet the paper makes clinical recommendations about vulnerable populations (desisters/detransitioners) without any formal ethical oversight or patient/public involvement.
- Reliance on potentially outdated and methodologically flawed desistance statistics: The paper cites child desistance rates of 98%-73% and 85% from Ristori & Steensma (2016) and Steensma & Cohen-Kettenis (2015), but these figures have been heavily criticized for methodological issues including conflation of gender non-conformity with gender dysphoria, and the paper itself acknowledges that pre-2000 studies likely included children without true GD—yet still presents these high desistance rates without adequate critical analysis.
- Contradiction in cohort applicability: The paper extensively documents five major changes to the recent patient cohort that make prior research potentially inapplicable ('our evidence-base is based on previous cohorts that may not be applicable to the current population'), yet simultaneously relies on that same prior research to support clinical recommendations and theories of desistence/detransitioning.
- Circular reasoning in theoretical claims: The paper states 'For some people, a period of gender transitioning that ends with desisting/detransitioning is an important part of a developmental trajectory' without empirical evidence to support this specific claim—this appears to be an assertion rather than a finding, and the cited sources (Churcher Clarke & Spiliadis, 2019; Steensma et al., 2011) do not directly support the 'developmental trajectory' framing for transitioning-then-desisting.
- Sampling bias acknowledged but not addressed in conclusions: The paper explicitly notes that 'those who are unhappy about their transition may be less likely to take part' and that follow-up studies have 'high rates of drop out' with 'low numbers making conclusions difficult,' yet proceeds to draw clinical implications and recommendations despite these acknowledged data limitations.
- Potential contradiction regarding sexual orientation interpretation: The paper reports Steensma et al.'s (2011) finding that '100% of persisters were same-sex attracted' but interpreted this as confirming they 'must be the opposite sex,' while desisters 'did not consider their same-sex attraction a factor in gender identity'—this framing appears to impose a particular theoretical interpretation on persisters' identities that may not reflect their own understanding, and the 100% figure seems unusually absolute for a clinical sample.
- Lack of primary data or original research: The paper contains no original empirical data, interviews, or systematic analysis, yet makes specific clinical recommendations including for medical professionals who helped patients transition to remain available for detransition care—without evidence that this is feasible, safe, or desired by patients.
- Possible selection bias in cited literature: The paper does not cite any critical perspectives on desistance research methodology (such as Temple Newhook et al., 2018, which is only referenced indirectly through Zucker's response), potentially creating an imbalanced presentation of the evidence base.
Key Findings
- Desisters and detransitioners—people who stop or reverse gender transitions—exist but are often overlooked in research and clinical care, with no established protocols to support them.
- Reported desistance rates vary dramatically (from 73% to 98% in children), but current data is unreliable due to changing diagnostic criteria, sampling biases, short follow-up periods, and a rapidly evolving patient population.
- Today's gender clinic patients differ significantly from past cohorts: there are far more adolescents, more assigned-female-at-birth patients, more non-binary individuals, more who have already socially transitioned, and more with co-occurring conditions like autism or mental health issues.
- Common factors associated with desistance include lower intensity gender dysphoria, greater body acceptance, resolution of contributing issues like homophobic bullying or family difficulties, and eventual gay or lesbian identity.
- Clinical care should be non-judgmental, view gender and sexual identity as potentially fluid, address social context and support systems, connect people to peer groups, and ensure access to medical professionals who can help reverse prior interventions when needed.
Abstract
The number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological wellbeing (de Vries et al., 2014). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimise persisters’ experiences (Zucker, 2018). Certainly, despite their presence in all follow-up studies of young people who have experienced Gender Dysphoria (GD), little thought has been given to how we might support this cohort. Levine (2017) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning - confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
Summary
This paper highlights the urgent need for research and clinical guidelines to support individuals who desist from or detransition after gender transition, noting that while this population has been documented across follow-up studies, they remain largely overlooked by professionals and activists. The authors review existing prevalence data and theories about why people desist or detransition, identify significant methodological limitations in current research—particularly regarding changes in recent patient cohorts—and offer preliminary clinical recommendations for providing non-judgmental, flexible support. They emphasize that with rising referrals to gender services and evolving patient demographics, developing an evidence base and clear protocols for this population is both timely and essential.
Conclusion
Research with populations who desist and detransition is in its infancy and little is known about how best to work with this growing population. While there is increasing recognition of the need for support for those who require it, there are still no clear guidelines on how to do this work. We are at an important juncture where our evidence-base is based on previous cohorts that may not be applicable to the current population of desisters and detransitioners; it is prudent to consider their needs alongside those who go on to identify as trans for life.