Detransition, Posttraumatic Stress Disorder, and Moral Injury
In recent years, there have been increasing reports of people who had undergone hormonal and/or surgical gender transition and later detransitioned (stopped or reversed gender transition). Detransition and regret experiences are complex, often involving intertwined physical and mental health challenges.
A new peer-reviewed publication by psychiatrists Clayton and McDeavitt argues that the distress suffered by some detransitioners is consistent with the diagnosis of "posttraumatic stress disorder" (PTSD), with the medical gender transition representing the traumatic event. Further, the authors suggest that the concept of "moral injury"—which has recently made its way into the DSM classification system, and which broadly refers to "the psychological damage inflicted on an individual upon realizing a profound betrayal by individuals in positions of authority"—may also be clinically relevant.
These two diagnostic concepts may aid clinicians to better conceptualize the psychological distress detransitioners may experience, with the goal of providing this vulnerable patient group with appropriate assessment, diagnosis, and treatment.
Posttraumatic stress disorder/PTSD (DSM-5-TR F43.10; ICD-11 6B40)
PTSD is a psychiatric disorder that occurs in some people who have experienced a traumatic event. It is characterized by four symptom clusters: intrusive symptoms (such as distressing memories, nightmares, and flashbacks); avoidance of feelings, memories, and reminders of the event; negative alterations in cognition and mood; and alterations in arousal and reactivity. To qualify for the diagnosis, the symptoms must persist for more than a month and cause significant distress or impair daily functioning.
The authors of the new paper posit that some detransitioners may be experiencing PTSD, with the medical gender transition serving as the major traumatic event. The physical changes of gender transition can be categorized into anticipated (and often desired) effects—such as deep voice and loss of breasts for females, and testicular loss for males—and treatment complications, such as urinary incontinence and sexual dysfunction. Upon detransition, not only the complications, but also the previously desired changes can become deeply traumatizing, leading to "intense feelings, including horror, helplessness, anguish, despair, self-disgust, betrayal, rage, guilt, and shame."
The authors explain how previously desired changes can come to be perceived as traumatic over time by drawing a parallel with female genital mutilation/cutting (FGM/C)—a practice that is embedded in some cultures.
At first, girls and young women, who are most commonly under age 16 when they undergo FGM/C, may not experience it as traumatic and may have no PTSD symptoms in the immediate aftermath. However, as the women move out of their home cultural context and encounter differing cultural perspectives on FGM/C practices, their perceptions may shift. Their previous self-concept of "seeing oneself as a clean and honorable woman” may change to one of “a mutilated woman and/or abused child, robbed of her sexuality and injured for life”—which may lead to the development of PTSD symptoms.
In the course of this psychological process, known as "hitting bottom" — a concept drawn from the addiction literature — a woman "undergoes a profound attitudinal transformation at a deep ('bottom') psychological level, opening up a painful shift of feelings from pride and honor to ones of shame and mourning." Notably, some women who speak out against FGM/C experience condemnation by their community, including being harassed and accused of destroying their culture.
While noting that PTSD may be an applicable diagnostic framework for some detransitioners who experienced their transition as regrettable, the authors also consider the potential objections and respond to each. In addition, they note that not all detransitioners will qualify for the PTSD diagnosis, and that determining this requires a clinical evaluation. The authors further note that some patients regret their medical transition but have not detransitioned, including many who wish to detransition but feel unable to do so. Although the paper focuses on detransitioners, the same trauma-informed concepts of PTSD and moral injury may be relevant to these patients as well.
Moral injury (code Z65.8)
The authors posit that for detransitioners who experience profound regret, PTSD is unlikely to be the entire clinical picture: "these patients are also likely to have suffered a substantial degree of moral injury."
When the trauma is not accidental but happens at the hands of a trusted caregiver, the risk of developing PTSD is heightened and its symptoms can be worse. The betrayal involved is captured in the clinical concept of "moral injury," which was incorporated into the DSM-5-TR in September 2025 under code Z65.8.
Moral injury broadly refers to "the psychological damage inflicted on an individual upon realizing a profound betrayal by individuals in positions of authority." Morally traumatic experiences are events that disrupt a person's sense of right and wrong, or their sense of goodness regarding themselves, others, or institutions. The authors note that "moral injury can involve a diverse array of emotions and cognitive responses, including, but not limited to, feelings of guilt, shame, disgust, lack of self-forgiveness, anger, trust issues, inability to forgive others, loss of faith, and moral questioning."
In the case of detransitioners, the previously inflicted moral injury is likely to deepen when influential gender clinicians dismiss or make light of detransition experiences. The authors cite public comments by such clinicians, who call the term "detransition" itself "invalidating," or claim that young patients who undergo mastectomies and later want breasts again can just "go and get them." Research also suggests that detransitioners who return to the clinical settings that provided their transition may encounter "detransphobia," a term for detransition-related stigma, discrimination, and social rejection.
The “moral injury” code Z65.8 can complement an existing diagnosis, such as PTSD or depression, or it can stand alone. When moral injury accompanies PTSD, the PTSD is particularly difficult to treat unless the moral injury is recognized and addressed.
Implications for clinical management
While clinical recommendations were outside the scope of the paper, the authors made several observations. Chief among them is that psychotherapy alone may be insufficient to alleviate the distress. A range of additional steps is needed both in the clinical and societal contexts.
Clinically, as in other contexts of PTSD and moral injury, the acknowledgment of the injury itself is essential. Societally, it is important to engage in community efforts aimed at understanding and reintegrating individuals who have experienced these injuries, and to foster a shared sense of responsibility for the injury sustained. Finally, for some individuals, their path to recovery may “take the form of social action and pursuing justice.”
The authors note that although “the trauma cannot be undone, some may feel that holding clinicians legally accountable for their actions is not only important for their personal well-being but also for the health of the broader society. This sense of a ‘survivor mission’ may assist some individuals toward resolving trauma.”
SEGM Take-away
This important paper adds to the growing conversation about detransition and regret and will be of value to all professionals who work with individuals who have undergone medical gender transition and later regret it and/or detransition. It encourages us to listen, understand, and support those who are grappling with serious physical and psychological harms following medical transition. This paper should be of particular interest to the growing number of detransition services, including the new services in the UK and the hospitals establishing detransition centers in the United States following settlements with the Justice Department.
As the authors point out, the fact that the result of hormonal and surgical interventions for gender dysphoria can prove to be "psychologically debilitating" for the patients has long been acknowledged. This is, in part, the reason why the early guidelines in transgender medicine set out strict eligibility and readiness criteria and recommended careful and extended mental health assessments. However, the authors describe how the awareness of the risk of harm of gender transitions, which used to be front and center of clinical decision-making, gave way to the "gender-affirming" paradigm. This paradigm devalued psychological assessments and progressively lowered minimum age requirements, extending medical transition to children and adolescents.
The rate of hormonal discontinuation, detransition, and regret is not well-quantified. It is, however, far from trivial: the paper references estimates of up to 30% for hormonal discontinuation for a range of reasons, and up to 10% for explicit detransition and regret. As a growing number of countries implement evidence-based restrictions on youth gender transitions in an attempt to curb future harm, how to care for those who have already undergone transition and now seek to reverse it represents an increasingly urgent clinical question.
Clinicians need to develop competency in taking care of this vulnerable and growing population. The authors posit that two clinical concepts are already available to help mental health practitioners working with this population—the diagnosis of "PTSD," which is already available in both the DSM and ICD frameworks, as well as the concept of "moral injury." Conceptualizing detransition through a trauma-informed lens, within the existing diagnostic frameworks, allows mental health professionals working with this population to better understand their experiences, and provide them more effective care.
We concur with these assessments. And while the damage of hormonal and surgical transition cannot always be undone, we join the authors in acknowledging the "strength, bravery, resilience, and their capacity to heal and live fulfilling lives despite the challenges" exhibited by the current generation of detransitioners.
Note: One of the two authors, A. Clayton, is affiliated with SEGM, and SEGM paid the open-access fees for this publication.