BACKGROUND: Regret after gender-affirming surgery is considered a rare outcome. There is a paucity of literature examining the incidence and/or etiology of surgical de- and re-transition. Coupled with the current issues in access and barriers for those seeking gender-affirming surgery, research in this field is extremely controversial. There are currently no professional guidelines or resources for providers who encounter patients who experience regret and/or seek detransition. In this paper the authors try to answer the question of how frequently gender surgeons are confronted with patients seeking the above care and what the current controversies are surrounding this very important topic.
METHODS: An anonymous survey was sent to all surgeons who registered for the WPATH conference in 2016 and USPATH conference in 2017. We asked respondents to report the number of patients encountered who expressed regret or sought detransition, the characteristics of the patients, surgical history, reasons cited for detransition, and whether any reversal procedures were performed. The responses were analyzed using descriptive statistics.
RESULTS: 46 surgeons (30%) responded to the survery. 67% of providers have been in practice for greater than 10 years and most surgeons practice in the United States (69%) followed by Europe (22%). Surgeons were asked to select a range representing the number of transgender patients they have surgically treated, and this amounted to a cumulative number of approximately 22,725 patients treated by the cohort. 49% of respondents had never encountered a patient who regretted their gender transition or were seeking detransition care. 12 providers encountered 1 patient with regret and the rest encountered more than one patient. This amounted to a total of 62 patients. There were 13 patients who regretted chest surgery and 45 patients who regretted genital surgery. The composition of the patients who sought detransition is as follows: 16 trans-men, 37 trans-women, and 6 non-binary patients. The most common reason cited for detransition was change in gender identity (22 patients) followed by rejection or alienation from family or social support (8 patients) and difficulty in romantic relationships (7 patients). Chronic post-operative pain was also cited as a reason for detransition. 7 trans-women who sought detransition had vaginal stenosis, 2 had rectovaginal fistulae, and 3 had chronic genital pain. 2 trans-men who sought detransition had a urethral fistula and one had a urethral stricture. 9 of the 46 respondents performed a total of 38 detransition procedures.
91% of respondents stated they would require a mental health evaluation prior to detransition and 88% of respondents feel that WPATH SOC 8 should include a chapter on detransition.
CONCLUSION: Regret after gender-affirming surgery is an exceedingly rare event. Reasons for regret or detransition are diverse, ranging from change in gender identity to societal and relationship pressures to post-surgical pain. It is not uncommon for detransition to be associated with surgical complications. Guidelines need to be developed to assist surgeons, patients, and payors in managing these rare events.