Review of "Preventing transition 'regret'"

Assignment for seminar. Figured why not post?

MacKinnon, K.R., Ashley, F., Kia, H., Lam, J.S.H., Krakowsky, Y., Ross, L.E. (2021). “Preventing transition ‘regret’: An institutional ethnography of gender-affirming medical care assessment practices in Canada.” Social Science and Medicine, 291.  https://doi.org/10.1016/j.socscimed.2021.114477

This study presents an institutional ethnography conducted in 2017-2018 examining clinical assessment practices at Canadian gender clinics, with a focus on clinical attempts to predict and prevent transition regret and detransition. The authors argue that “despite the low prevalence of ‘regretful’ patient experiences, and scant empirical research on ‘detransition,’ these rare transition outcomes profoundly organize the gender-affirming medical care enterprise.” Finally, the authors argue that regret and detransition are “unpredictable and unavoidable clinical phenomena,” arguing that predicting and preventing regret is playing an outsized role in current clinical practice. 

The article’s basic premises — e.g., that transition regret and detransition are rare outcomes — are assumed, not evidenced. The authors ignore substantial evidence to the contrary and overlook reasons to question the existing literature on detransition and transition regret (e.g., the Turban 2021 study was a self-selected sample that recruited currently transgender-identifying participants from trans websites; in other words, researchers made multiple decisions that would predictably exclude and/or underrepresent detransitioners, who by definition no longer identify as trans and are unlikely to frequent trans websites). Other studies of transition outcomes cited by the authors have been critiqued for short follow-up times (typically one year) and heavy loss to follow-up among study participants, leaving outcomes in doubt. The authors ignore research (e.g., Singh, Bradley & Zucker, 2020) finding that the majority of gender-dysphoric youth, including those presenting with persistent cross-gender identification, desist as they move through puberty, becoming comfortable in their bodies, with many simply growing up to be gay — as recently as the mid-2000s, gender dysphoria was understood as a normal stage of homosexual development! — a significant and justifiable source of caution for providers contemplating pubertal suppression, which evidence suggests may lock children into transition by blocking the developmental stage that resolves dysphoria in the overwhelming majority of cases.

The literature review also wildly overstates the case for biomedical interventions and thus understates the case for provider caution, which the authors criticize as manifestations of “cisnormativity” and “transnormativity.” The evidence base for biomedical interventions has recently (in the two years leading up to the publication of this paper) been evaluated by regulatory agencies like National Institutes of Health and Care Excellence in the United Kingdom and found lacking (e.g., quality of evidence for suppressing puberty in minors was found to be “very low,” with significant risks flagged around cognitive development, bone density, self harm, suicidal ideation, and other complications). Authors should engage honestly with the literature—including its gaps, limitations, and contestations. [It may also be of interest that more than one author on the paper has specifically advocated against ethical medical research into detransition, yet now decries the lack of such research.] The authors do not engage the literature on child and adolescent development, reducing medical provider caution around youth transition to a question of preventing regret and detransition alone. 

The authors are fundamentally incapable of or unwilling to take the possibility of transition regret and detransition seriously, never even referring to ‘regret’ or ‘detransition’ without the use of scare quotes. The authors write that there is “no evidence that regret or detransition are necessarily negative outcomes caused by medical failures.” Yet studies like Vandenbussche (2021), which the authors briefly cite but do not engage in any depth, specifically flag regret and detransition as negative outcomes according to patient experience and patients do blame predictable and preventable medical failures — such as inadequate screening for mental health comorbidities and haste in providing cross-sex hormones and surgeries — for these negative outcomes. Instead, the authors criticize provider concerns about transition regret and detransition for viewing ‘gender-affirming care’ as “uni-directional,” rather than allowing room for a person to undertake serious biomedical interventions and then reverse course or ‘regret’. This is an unconventional understanding of the role of medical providers, still tasked with ‘do no harm.’ The authors do not interview anyone who regrets transition or detransitioned about their experiences navigating clinical assessments — a substantial limitation on the authors’ ‘finding’ that transgender patients would not support changes to the assessment process to better predict and prevent regret (though they include one transgender person who was dissatisfied with surgical results but did not regret transition). 

The authors’ apparent ideal of “gender-affirming care” is patients accessing life-altering biomedical interventions (including removal of the uterus, ovaries, and breasts) based on patient self-assessment, not clinical assessment of the appropriateness of treatment and likelihood of positive outcomes. They consistently understate the seriousness and irreversibility of medical interventions, and dismiss concerns over potential medical malpractice (both from a legal perspective and the perspective of providers committed to providing ethical care in their patients’ long-term interests) as “cisgender anxieties projected onto trans patients who are seeking medical care.” They do not explore potential alternative explanations for medical provider caution. For example, the authors allude to but do not explore tensions around changing conceptions of the role of the medical provider and patient-consumer in determining diagnosis and treatment. Until recently, medical providers diagnosed patients with gender dysphoria (previously gender identity disorder), then evaluated appropriate treatment pathways. The affirmative-care model now in vogue moves away from medical provider diagnosis to patient self-identification. Patient-consumers seeking biomedical transition now frequently present without gender dysphoria (the authors refer to the expectation that patients referred for biomedical interventions experience gender dysphoria as harmful “transnormativity”), yet expect medical providers to comply with patient self-diagnosis and prescribe medical procedures, under a medical model. It would be understandable for medical providers to exercise caution under these ever-changing conditions — no ‘undue’ concern about the possibility of detransition necessary.

The authors do not define key terms (e.g., “transgender”) and use loaded language that enforces a particular ideological perspective on transition-related medical interventions (“gender-affirming care” rather than more neutral language). The choice of language has the virtue of making the authors’ ideological commitments abundantly clear but unnecessarily obscures and complicates discussion of complex case presentations and clinical practices. The authors work backward from their desired conclusions: because we want ‘gender-affirming care’ to be available more or less on demand, therefore regret and detransition cannot be taken seriously (“regret”), nor could these outcomes be predicted or prevented by more scrupulous clinical assessments. When the evidence suggests otherwise, the authors do not engage with it.

The most intriguing question the authors raise — which deserves further investigation — is the question of how clinical practices that aim to predict and prevent regret and detransition (among other clinical purposes) may push patients seeking biomedical transition to conceal mental health comorbidities. If patients are concealing mental health comorbidities in the hopes of accessing transition, this presents a serious problem for providing informed and ethical assessment and care. Such an article might be a better use of the authors’ considerable energies.