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Detransition Rates Unknown: Systematic Review Exposes Critical Gaps in Long-Term Data

Prevalence of detransition in persons seeking gender-affirming hormonal treatments: a systematic review

cohort studydetransitionpuberty suppressiongender exploratory therapymedical ethicsgender dysphoriasystematic review
Authors
Eva Feigerlova
Year
2024
Journal
Journal of Sexual Medicine

Methodological Limitations

  • Only one researcher participated in this work, which limits the collection of information and analysis of the collected data, as other researchers would probably suggest other points of view.
  • The vast majority of the studies included in the present analysis were retrospective and unblinded. Data were thus available to the investigators, which could influence the results.
  • Most studies were not sufficiently powered to detect detransition rates.
  • All of the included studies were heterogeneous regarding definitions of detransition used and the study design: their numbers were too small to be statistically relevant, their time frame was insufficient, they did not use patient-level data, or they did not consider confounding factors.
  • Fourteen of fifteen studies had retrospective designs, and only one was an uncontrolled prospective observational study.
  • Five studies did not analyze primary patient-level data, but reported secondary use of existing data (Butler et al., Cavve et al., Cohen et al., Glintborg et al., Roberts et al.).
  • The follow-up times were either insufficient or not reported in the majority of studies.
  • The certainty assessment of the included studies using the GRADE approach revealed a very low overall quality evidence.
  • The studies included in the present analysis reported variable ages at the start of GnRHa and/or GAHT, which may be due to long waiting lists or loss to follow-up with treatment initiation at another center.
  • Most identified cases were from the Netherlands, the USA, the United Kingdom and Denmark; therefore, the results may reflect country-specific protocols, and care provided by different health care centers within each country was variable, further limiting interpretability.
  • The observational design of the studies did not enable conclusions about any possible effect of GnRHa and/or GAHT on gender identification.
  • For several studies, the outcome measures were not clear (Butler et al., Cavve et al., Cohen et al., Carmichael et al., McCallion et al., Roberts et al., Van der Loos et al.).
  • Butler et al. used discharge reports, which may be a source of bias, and a follow-up time was not reported.
  • Carmichael et al. used an uncontrolled study design with a small sample size (N=44) and included a highly selected group of participants; moreover, the sample size varied during follow-up due to missing data.
  • Cavve et al. used secondary data and the accuracy of the outcome measures was unclear.
  • Cohen et al. did not analyze patient-level data and a follow-up time was not reported.
  • Gupta et al. suffered from missing data, which introduced a bias in data interpretation.
  • Roberts et al. used data from a single insurance system and reported unclear results given that 60.9% of the adult population had a 35.6% discontinuation rate and 39.1% of the minority population had a 25.6% discontinuation rate.
  • Van der Loos et al. (2023) was not suitable for measuring detransition as it covered only a short puberty suppression period.
  • Age and treatment modality were not systematically reported across studies.
  • Assigned male/female ratios could not be determined because of missing data in both pediatric and adult populations.
  • Variable sample sizes made comparisons between studies difficult.
  • The authors acknowledge that pooled estimates of the number of people who detransition due to a change in identity are likely to be overinflated because research blends different cohorts, yet they still present pooled ranges.
  • The definition of detransition applied in this review was broad and inclusive (including those who changed request before any treatment, those who discontinued GnRHa, and those who discontinued GAHT), which may conflate distinct phenomena with different clinical implications.
  • The review excluded surveys on online communities due to susceptibility to self-selection and nonresponse bias, but this may have excluded relevant data sources on detransition experiences.

Key Findings

  • Detransition rates are relatively low: shifts in treatment requests before any medication ranged from 0.8-7.4%, puberty blocker (GnRHa) discontinuation from 1-7.6%, and hormone therapy (GAHT) discontinuation from 1.6-9.8%.
  • The 15 included studies were highly heterogeneous and generally low quality—most were retrospective, had insufficient follow-up times, used inconsistent definitions of detransition, and failed to account for confounding factors like social or financial pressures.
  • Reasons for stopping treatment varied widely and were not limited to identity changes; they included side effects, financial barriers, social issues, treatment goals being met, and poor compliance, making it difficult to isolate true identity-based detransition.
  • There is no standardized definition of detransition across studies, with some counting anyone who stopped identifying as transgender regardless of medical steps taken, while others required actual hormone discontinuation with intent to revert to birth-assigned gender.
  • The authors conclude that detransition remains insufficiently studied and call for well-designed long-term prospective research with consistent measurement tools, adequate follow-up, and control for confounding variables to better inform healthcare providers and policymakers.

Abstract

Background: Despite recent evidence of the benefits of gender-affirming medical procedures, data in the literature indicate emerging demands of detransition and regrets while suggesting potential sources of bias in different datasets, including a nonconsensual definition of detransition. Aim: The present systematic review aims to summarize the existing research regarding the prevalence of detransition in transgender persons who requested or started receiving gonadotrophin-releasing hormone analogs (GnRHa) and/or gender-affirming hormonal therapy (GAHT). Methods: A systematic literature search (CINAHL Plus, Cochrane Library, Google Scholar, MEDLINE, Web of Science, Sage Journals, Science Direct, Scopus) for quantitative studies was conducted up to May 2024. All eligible studies were assessed using the Strengthening the Reporting of Observational Studies in Epidemiology statement. The risk of bias was assessed using the National Institute of Health quality assessment tool. The present analysis follows the PRISMA statement for systematic review articles and the synthesis without meta-analysis recommendations. Outcomes: The primary outcome was the point-prevalence proportion of detransition events as a percentage in the population of transgender persons who were considered eligible for treatment or had initiated GnRHa and/or GAHT. Results: Fifteen observational studies involving 3804 children and adolescents and 3270 adult participants were included in the 3212 screened studies. Five studies reported a change in request before starting GnRHa, five studies reported GnRHa discontinuation, and nine studies reported GAHT discontinuation. The point-prevalence proportions of shifts in requests before any treatment ranged from 0.8-7.4%. The point-prevalence proportions of GnRHa discontinuation ranged from 1-7.6%. The point-prevalence proportions of GAHT discontinuation ranged from 1.6-9.8%. All of the included studies were heterogeneous regarding definitions of detransition used and the study design: their numbers were too small to be statistically relevant, their time frame was insufficient, they did not use patient-level data, or they did not consider confounding factors. Clinical implications: Quality measurement tools are needed, as are monitoring standards, and both are important for health outcomes and guarantee the attention of health care providers and policy-makers. Strengths and limitations: The unique features of this analysis are its restrictive inclusion criteria compared with those of previous reviews, such as a strict definition of detransition and a focus on empirical studies only. However, most of the studies were retrospective and unblinded, and most were not sufficiently powered to detect detransition rates. Conclusion: Taken together, the results of the present analysis show that detransition in persons undergoing gender-affirming treatment has been insufficiently investigated, highlighting the need for long-term follow-up studies.

Summary

This systematic review examined the prevalence of detransition among transgender individuals who sought or started gender-affirming hormonal treatments, analyzing 15 observational studies with over 7,000 participants. The review found that point-prevalence proportions of detransition ranged from 0.8-7.4% before treatment, 1-7.6% for puberty blocker discontinuation, and 1.6-9.8% for hormone therapy discontinuation, though the authors concluded that existing research remains insufficient due to heterogeneous definitions, short follow-up periods, and methodological limitations. The study emphasizes the critical need for standardized measurement tools and well-designed long-term prospective studies to better understand detransition and inform clinical care and policy decisions.

Conclusion

This review provides the point-prevalence proportions of detransition among persons who sought hormonal treatments (GnRHa and/or GAHT). Taken together, the results of the present analysis indicate that detransition in persons undergoing gender-affirming treatment has been insufficiently investigated. Quality measurement tools are needed, as are long-term follow-up and monitoring standards. The present study highlights the need for well-designed prospective studies to evaluate the number of transgender persons experiencing detransition after starting GnRHa and/or GAHT and associated factors and to detect individuals at a greater risk of detransition. These data are important for health outcomes and to guarantee the attention of health care providers and policy makers.