December 23, 2021

Case Study Considers Detransition

Therapist critiques "gender-affirmative" care model for youth

What happens when a young person's intensely experienced desire to undergo medical transition is granted, with minimal attention paid to the factors contributing to the development of gender dysphoria, and with no attempts to ameliorate the distress non-invasively first? A new publication, Gender Detransition, a Case Study by Lisa Marchiano, presents a case study of a young natal female detransitioner. This case study is an effort to elucidate the complex characteristics and issues involved in the desire for transition and detransition in the novel population of adolescents with post-puberty onset of gender dysphoria. Marchiano points out the limitations of the "gender-affirmative" care model and calls for further research to better understand this population.

Key Messages

  • This case study of a young natal female detransitioner describes the loss of a primary attachment figure at age 9, and lack of parental attention, and social media influences along with diagnoses of an eating disorder and attention deficit hyperactivity disorder (ADHD) as potential triggers of GD and trans identification at age 14.
  • The patient was immediately affirmed by the school psychologist, who encouraged the patient’s mother to allow her to medically transition. However, the parents did not support medical transition until the patient was 18 years old.
  • Medical transition was initiated at age 18 after a 30-minute visit with a physician’s assistant. The transition produced initial euphoria that quickly subsided and was replaced by anxiety, anger and intensely self-destructive moods and behaviors, including suicidal ideation and two hospitalizations. The patient suspected that testosterone contributed to her deteriorating mental health. She detransitioned and re-identified as female.
  • Treatment focused on an exploration of the patient’s processing of loss, coming to terms with grief over the lack of an adequate parental connection, and improving emotional regulation skills. Therapist and patient explored the role of trans identification as a strategy to help the patient to manage social difficulties at school and complex issues in her relationship with her mother.

Marchiano observes, “Pursuing transformation through disordered eating and then gender transition had the effect of concretizing her emotional losses. Displacing painful losses onto her body seemed to allow her to avoid her intolerable grief and gain the illusion of control.  Transition into the masculine may have been an attempt to compensate for an unbearably vulnerable aspect of her wounded feminine self.”

SEGM Perspective

The number of adolescents presenting with gender dysphoria (GD) has dramatically increased throughout the Western world, with the sharpest increase observed during the past several years. In addition, the sex ratio of those presenting with GD has flipped from predominantly natal males to primarily natal females. Concurrently, treatment of young people with GD also has changed: increasingly, the "gender-affirmative" model of care has become the predominant intervention for GD. Under this model of care, puberty blockers are provided to children at the earliest sign of puberty (as young as 8-9 for females); cross-sex hormones are provided at 14-16; and according to the latest WPATH draft guidelines released earlier this month, mastectomy can be performed on 15-year olds, while the removal of ovaries, uterus and testes can happen at 17. Many providers of "gender-affirming" interventions further push these boundaries, performing mastectomies on children as young as 13.  Extensive psychological evaluations, which were required when the Dutch first introduced this model of care in the 1990's, are either no longer required, or are highly abbreviated. In the latest draft WPATH v8 guidelines, the concept of a minor's wish appears to have fully supplanted the concept of medical necessity.

Given the novelty of the practice to provide hormones and surgeries to any young person who wishes it, and the average "honeymoon" period lasting between 5-10 years, the full extent of regret and medical harm will not be known for several years. However, we are already starting to see early evidence of problems with the "gender-affirmative" treatments. The number of detransitioners has been growing, as evidenced by three studies published earlier this year. The new case study by Marchiano offers valuable insight and guidance for clinicians working with young people with gender dysphoria and/or trans identities. In this case study, Marchiano presents an excellent and detailed analysis of potentially precipitating factors for GD and explains the serious limitations of the "gender-affirmative" model.  SEGM concurs with Marchiano’s assertion that the "gender-affirmative" model "encourages the patient to make critical health decisions, including surgical interventions, based on beliefs rather than ‘facts,’ and that the gender affirmative model of care perhaps too often confirms prematurely a patient’s belief and forecloses the opportunity for thinking symbolically about this distressing experience.” Marchiano cautions against “colluding with an avoidance of reality” and opines that the affirmative care model “concretizes psychic pain, locates it in the body, and seeks biomedical treatments for it.”

If you would like to read more about the phenomenon of detransition, we recommend the following sources:
 

Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare. 2022; 10(1):121. https://doi.org/10.3390/healthcare10010121

D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049

Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380

Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapyhttps://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126

Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case-note review. BJPsych Open7(6), e184. https://doi.org/10.1192/bjo.2021.1022

Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behaviorhttps://doi.org/10.1007/s10508-021-02163-w

Marchiano, L. (2021). Gender detransition: A case study. Journal of Analytical Psychology66(4), 813–832. https://doi.org/10.1111/1468-5922.12711

Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479