4. Outcomes — Transition & Detransition

What the long-term data actually shows for the adolescent cohort, and what we can and can't say about regret and reversal.

Why the old "low regret" numbers don't apply to today's adolescents

You'll see the figure "less than 1% regret" cited frequently in articles defending the affirmative model. The most common source is Wiepjes et al. (2018), the Amsterdam Cohort study of 6,793 patients between 1972 and 2015, which reported regret at gonadectomy of 0.6% (trans women) and 0.3% (trans men).

• That cohort was overwhelmingly adult. The kids who'd later define the modern surge weren't in the data.
• The Dutch gatekeeping process was extensive — multi-year psychological evaluation, assessment of comorbidities, requirements for stable identity over time. Almost no one who reached surgery in this cohort had presented within the previous 12 months. The contemporary US "informed consent" model is structurally different.
• "Regret at gonadectomy" is a narrow outcome. It captures people who explicitly returned to a clinic asking to reverse a specific surgical decision. It does not capture: people who detransitioned without surgical reversal, people who decided the transition was a mistake but didn't want to re-engage with medicine, people who quietly stopped hormones, or people who regretted hormones/social transition but not surgery.
• Dropout was massive. The original cohort lost track of a substantial portion of patients over the follow-up window. People who detransition often have particular reasons to not stay in touch with the clinic that medicalized them.

The "Dutch leaks" analysis (2024) re-examined the Amsterdam Cohort data and argued that when one accounts for patients who stopped attending the clinic and were classified as "lost to follow-up" rather than as detransitioners or regret cases, the implied regret figure could be as high as ~33%. This analysis is contested but the methodological point — that the official numbers undercount because of clinic-disengagement — is broadly accepted even by defenders of the affirmative model.

What more recent systematic reviews of detransition rates show

A December 2024 systematic review (PubMed) of detransition prevalence in hormone-treated patients reported:

• 1.6–9.8% point-prevalence for discontinuation of cross-sex hormones.
• 1.0–7.6% for discontinuation of puberty blockers.

These ranges are notably higher than the 0.3–0.6% figure for surgical regret. Several caveats:

• Discontinuation isn't the same as regret. Some people stop hormones for medical reasons, some because they identify as nonbinary and feel they've reached their goal.
• Follow-up is still short for the adolescent-onset cohort. The numbers will likely change as more time passes.
• Some detransitioners eventually re-transition; the picture is dynamic.

Littman 2021 — the 100-detransitioner survey

Littman's 2021 Archives of Sexual Behavior study directly surveyed 100 detransitioners — 69% natal female, 31% natal male — about their experience. The findings are extremely informative for the question "what do detransitioners themselves say happened?"

Satisfaction with transition vs. detransition:

• 69.7% dissatisfied with their decision to transition.
• 84.7% satisfied with their decision to detransition.
• 49.5% reported strong or very strong regret.

Reasons participants gave for detransitioning:

Critically — the dominant reasons given were internal realizations, not external social pressure. The narrative sometimes promoted in advocacy contexts (that almost everyone who detransitions does so because they were forced by family or society) is not what the largest direct survey of detransitioners shows.

Vandenbussche 2021 — 237 detransitioners' support needs

A parallel 2021 survey by Vandenbussche of 237 detransitioners (Journal of Homosexuality) asked about the reasons people detransitioned and what support they needed afterward. Top reasons:

• 70% — realized gender dysphoria was related to other issues
• 62% — health concerns
• 50% — transition did not relieve dysphoria
• 45% — found other ways to deal with dysphoria
• 44% — unhappy with social changes
• 43% — change in political views
• 23% — unprompted, indicated internalized homophobia and difficulty accepting same-sex attraction had driven their initial transition (this was not a survey item — respondents volunteered it).

Vandenbussche's study also found significant unmet medical and psychological needs for detransitioners — most reported difficulty finding clinicians willing to help them detransition or treat the medical consequences of their transition.

Mental health outcomes — what does transition actually deliver?

The honest answer: it's mixed, and the evidence is weaker than the public conversation suggests.

The Cass Review's systematic review of the outcomes literature (2024) concluded:

"No evidence was found that social or medical transition/pathways reduce suicides... There is insufficient/inconsistent evidence about the effects [of puberty blockers] on psychological or psychosocial wellbeing, cognitive development, cardio-metabolic risk or fertility."

The 2025 HHS review reached similar conclusions: "The quality of evidence on the effects of any intervention is low, and evidence on harms is sparse."

This isn't to say no one benefits from medical transition — many adults clearly do. The question is whether the affirmative protocol applied to adolescents in the new cohort, with their high rates of comorbid mental-health conditions and uncertain etiology, reliably delivers the mental-health benefits its proponents claim. The systematic reviewers across multiple countries have independently concluded that the evidence base does not support the strong claim of benefit, especially given the magnitude and irreversibility of the interventions.

The puberty blocker question specifically

Puberty blockers were originally proposed (in the Dutch protocol) as a "pause button" giving adolescents time to think before making irreversible decisions. The data has not supported this framing:

• 96–98% of adolescents who start puberty blockers proceed to cross-sex hormones in most published cohorts. (For comparison: in the historical "watchful waiting" approach, roughly 60–90% of children with GD desisted by adulthood — see Section 1.) Once on blockers, almost no one desists.
• Bone density is compromised by prolonged puberty suppression and is only partially restored by later sex-hormone administration. The Cass Review identified bone-density decline as a clear adverse effect.
• Fertility and sexual function: blockers followed directly by cross-sex hormones (the typical trajectory) prevent natural puberty entirely, meaning gonadal tissue never matures. This permanently impairs fertility for some patients, and sexual function (and orgasmic capacity) for many.
• Neurocognitive development: the effects of sex-hormone deprivation during the adolescent brain-development window are not well-studied. The Cass Review described this as a serious evidence gap.
• The "buy time to think" justification has been substantially abandoned in the European reviews. The NHS England now only prescribes puberty blockers under research protocols.

Detransitioners' voices — what they consistently describe

The Pique Resilience Project (Helena, Jesse, Dagny, Chiara — four young women who detransitioned in their 20s) and Chloe Cole (who detransitioned in her late teens after a double mastectomy at 15) are the most public faces of detransition in the US. Their accounts — and those collected in clinical and journalistic projects — converge on a recognizable pattern:

• The original distress was real, but they now think the explanation they adopted was wrong.
• The underlying issues turned out to be trauma, anxiety, sexual orientation confusion, autism, eating disorders, or sometimes just developmental adolescent identity-formation that would have resolved.
• The medical transition did not solve the underlying distress; in many cases it added new problems (voice changes, body-hair changes, mastectomy scars, sexual dysfunction, infertility).
• They describe themselves as having been failed by clinicians who didn't ask hard questions before medicalizing them.
• Many describe the affirmative-care frame as having made it impossible to express doubt during their transition — friends, online community, and clinicians treated any hesitation as evidence of internalized transphobia rather than as valuable feedback.

It's worth noting that detransitioner voices are sometimes dismissed as politically motivated or as outliers. The peer-reviewed survey data (Littman 2021, Vandenbussche 2021) and clinical case reports broadly corroborate the pattern these individuals describe in public.

Outcomes specifically for transitioned adolescents (the new cohort) entering adulthood

• The Karolinska's internal review of their own pediatric patients (one of the triggers for Sweden's policy reversal) found the psychological improvements they had expected to see post-transition were not present. This was not publicly published but was acknowledged in policy documents.
• The 2020 UK Bell v. Tavistock judicial review pulled records of GIDS patients and found weak evidence of mental-health improvement post-blockers and post-hormones, contrary to clinic claims.
• A growing body of detransition case studies (e.g., the 9-patient series from Finland published in 2025, Archives of Sexual Behavior) describes adolescents who transitioned in the 2014–2019 window and detransitioned in their early 20s after realizing their dysphoria was downstream of trauma, autism, or mental health issues.
• Self-organized detransitioner communities (r/detrans, Beyond Trans, Post Trans, Detrans Voices) have grown rapidly since 2020 — providing community for thousands of mostly-young-adult women who transitioned as teens and are now reckoning with the consequences.

What is genuinely unknown — and probably won't be known with confidence for another 10–15 years — is what proportion of the 2014–2020 adolescent transition cohort will be satisfied with their decision long-term. The early signals from the detransitioner population are not encouraging, but base-rate calculations require longer follow-up than currently exists.