Hype-Disappointment-Reinvention Cycles in Transgender Medicine

Guest post by Kinnon Ross MacKinnon and Pablo Expósito-Campos

Jun 07, 2025

Kinnon MacKinnon is a Canadian trans man and assistant professor at York University. He began transitioning fifteen years ago, and for his PhD thesis in public health sciences at the University of Toronto, he studied gender-affirming care policy and clinical practices. Pablo Expósito-Campos is a Spanish cisgender PhD student in clinical psychology at the University of the Basque Country. Pablo’s thesis is a mixed-methods study of trans people’s and detransitioners’ experiences of gender-affirming healthcare.

MacKinnon and Expósito-Campos write on their Substack ‘The One Percent’:

Deliberations on the iatrogenic age and gender medicine reformers

We are interdisciplinary researchers who study gender-affirming healthcare. Our respective work draws from trans studies, mad studies, psychology, political economy of healthcare, and the philosophy of science. In recent years, we have both been studying detransition, or the act of stopping/reversing an initial gender transition due to a change in identity, and we are currently writing a book about it. Much of our research aims to build academic knowledge to understand detransitioners’ experiences of transgender medicine, their identities and ongoing care needs, and to spark informed, data-driven conversations. In a commentary article published in the BMJ, we urged that “detransition needs further understanding, not controversy.”

At the core of detransition research are fundamental questions about identity and medicine. How can we best support trans, gender nonconforming, and sexual minorities in systems of care never designed for them? How ought we respond to the unknowns surrounding the treatment of gender dysphoria? Detransition raises ontological questions about what gender dysphoria is and how it relates to other forms of psychological distress, suffering, and madness. Is gender dysphoria a type of mental disorder, treatable by the provision of gender-related hormones or surgeries? Could being trans be thought of as an aspect of neurodiversity, such that it is a normal variation in thinking, feeling, and behaving? Is the aim of transgender medicine to treat gender dysphoria or is it to affirm trans identity? Was psychiatry wrong all along to introduce the syndromes of transsexualism, gender identity disorder, and gender dysphoria? Even the DSM’s re-naming of the distress associated with discordance between gender identity and sex traits, and its evolving categorization and diagnostic criteria for gender dysphoria reflects on-going questions in the treatment of gender.

Many of the same historical and modern-day challenges animating the field of mental health—threats to knowledge, the availability of clinical resources, and consumer-survivor-patient movements—also shape trans medicine. This article aims to present an analysis of recent developments, focusing especially on conflicts over knowledge and beliefs about gender dysphoria and treatment for it.

This writing doesn’t intend to demonize any particular trans care model, nor to suggest that the gender-affirming medical model is a failure. Rather, it recognizes the cyclical nature of progress in mental health fields dealing with complex conditions, and the way that detransition, transition regret, and iatrogenic harm are being instrumentalized by larger political forces. Undoubtedly, social hostility towards trans people and gender-variance has played a vital role in all of the clinical cycles this article goes on to describe. The gender-critical movement cannot merely be understood as a response to the limitations of gender-affirming care; but it has derived power by leveraging detransitioners to critique trans medicine and trans rights, and by joining forces with anti-LGBTQ+ actors. Political restrictions on medical treatments for gender dysphoria are not justified by unexpected treatment outcomes that have not yet been well-studied or understood (like detransition).

Gender dysphoria and treating trans maladjustment

Within Trans Studies, the concept of “trans maladjustment” was coined by Cameron Awkward-Rich (2022) in his book The Terrible We: Thinking With Trans Maladjustment. It offers a crucial lens for understanding the complex relationships between trans identity, gender dysphoria, and persistent feelings of distress. Focusing especially on transmasculinity (trans men, butches, and other gender-diverse assigned females), Awkward-Rich spills ink contemplating the pitfalls of trans-affirming, popular discourses that divorced being trans from being mad/neurodivergent/disabled. Much of dominant trans-affirming discourses hinge on a rejection of disability and mental illness, which does not sit well with Awkward-Rich (and many other widely recognized transmasculine disability/trans studies scholars). Much of the book centres around thinking about a model of trans that thinks with madness, rather than against it.

To lay a foundation for thinking about mad trans lives, he suggests:

Briefly, trans maladjustment is my shorthand for the tight, durable association between trans identity and particularly bad feelings and mad habits of thought that show up again and again in transphobic and trans-affirmative discourse alike, things like depression, social withdrawal, unruly post-traumatic identity/affect, suicidality, dysphoria, feeling haunted, and so on (p. 6).

This concept captures the specific forms of distress and suffering that trans medicine seeks to address, but can sometimes fail at, which get expressed for trans people in many ways. It also comes up in detransition research, because common reasons to detransition include identity shifts, worsening gender dysphoria, mental health complexity, complications from treatments, or feeling that transitioning did not improve gender dysphoria. Though many factors can drive detransition, including societal prejudice towards gender-diversity, it is not uncommon for detransitioners to report being misdiagnosed, or that their dysphoria and suffering persisted despite hormonal and surgical treatments.

Trans medicine involves biomedical treatments to change sex traits, with a clinical aim of treating gender dysphoria: the distress experienced by patients who present with discordance between gender identity/gender role and natal sex characteristics. However, transgender/gender-diversity are phenomenologically heterogeneous and complex. Some trans people report not feeling any dysphoria or dissatisfaction with their natal sex traits, or only with specific characteristics, yet they might seek treatment. Some may feel there is no underlying condition to treat, yet request barrier-free access to hormones and surgeries without a mental health assessment or being diagnosed. Others report that treatments failed to help, worsened gender dysphoria, or harmed them in some way, and that clinicians should have held off on the body-changing treatments. Detransition/regret can occur in the context of receiving a new psychiatric diagnosis that had never been known prior to accessing hormones/surgeries. All of this makes decision-making fraught for gender clinicians and introduces some risks. Who is likely to benefit? Who is likelier to feel let down?

In a 2022 survey of 237 detransitioners (92% assigned female) published in the Journal of Homosexuality, 70% said they detransitioned because of realizing gender dysphoria was related to other issues, and 50% said transition did not help with dysphoria, while others reported mental health concerns arising from treatments. Another study published in 2025 in the Archives of Sexual Behavior described 9 detransitioners (7 assigned females) who returned to the gender clinic where they had originally received transition-related care, some pursuing breast reconstruction after mastectomy. Not unlike general trans/nonbinary samples, polydiagnoses were common, inclusive of mood disorders, psychotic disorders, borderline personality disorder, and dissociative disorders. Other studies support these observations. In recent years, detransition seems to occur more among assigned females, often several years or even decades after the initial gender transition.

While many explanations are being explored to make sense of these trends, questions abound about the etiology of gender dysphoria, the biopsychosocial aspects of treatment, and how frequently detransition outcomes even occur.

In his book On the Heels of Ignorance: Psychiatry and the Politics of Not Knowing, sociologist Owen Whooley (2019) traces the history of American psychiatry’s management of the unknowns in treating madness. Whooley documents the field’s efforts—from the asylum era to dream analysis to neuroscience—to treat its object: madness and psychological distress. He analyzes how its leaders have long managed disciplinary crises and existential threats.

(Note: For Dr. Awais Aftab’s review and critique of this book, you can check out this post. Spoiler: he finds Whooley’s proposal that madness is inherently unknowable to be “astonishing” and ultimately rejects this aspect of the book.)

After reading Whooley’s book, we couldn’t help but notice that his analysis maps powerfully onto current events and the management of uncertainty in the field of trans medicine. It also helps us to contextualize trans medicine’s efforts to treat and manage gender dysphoria—the madness encompassed by Awkward-Rich’s trans maladjustment. It especially applies to the emerging debates over evidence and outcomes that are occurring right now in academic journals, legislation, and in the court of public opinion, and highlighted by the United States’ Health and Human Services report on gender dysphoria treatment.

Whooley’s main thesis is centered on what he calls the hype-disappointment-reinvention cycle. This process is especially useful for thinking about the trajectory of clinical practices within trans medicine, including the modern gender-affirming medical model of care. The gender-affirming model divorces transness from madness and places low emphasis on diagnosis and assessment prior to referring patients for hormones/surgeries.

While trans medicine for adults has a long history dating back approximately 100 years, the gender-affirming medical model is historically distinct and took root via idiosyncratic clinical philosophies and political-economic constraints. This approach to initiating medical treatments for youth and adults alike was hyped up in the early-to-mid 2010s. During this period, at the backdrop of broader LGBTQ+ civil rights movements, conducting assessments to inform clinical decision-making became controversial in the field. For some researchers and clinicians, gender-affirming care became more about affirming trans people and gender diversity in society and expediting access to treatment, than addressing gender dysphoria. Also motivating changes in practice, North American clinics often prioritize neoliberal cost-containing and efficiency logics over individualized, relational, holistic care.

Some suggest that a formal diagnosis of gender dysphoria is unnecessary, harmful even, because it limits self-determination of gender identity. In an article published in 2025, authors explain how to conduct an assessment with gender-diverse children/youth, while also mentioning they are “agnostic” on the value of assessments, and that the assessment is not to determine whether someone is transgender. This makes sense, since transgender is a self-identity. But across medicine and the mental health fields, diagnosis and assessment are considered fundamental to guide treatment decisions.

While the gender-affirming clinical philosophy helped to liberalize access to treatments and to de-pathologize trans people, it began to reveal observable limitations about a decade later. Debates about the evidence for gender-affirming care, medical ethics, and detransition are now being politically instrumentalized around the world to ban trans medicine entirely and even to strip the United States of all LGBTQ+ health research for its recognition that sex and gender are discrete constructs (i.e., “gender ideology”).

Whooley proposes that a revolving process undergirds novel approaches to psychiatric care delivery, but that, quite often, epistemological threats to the knowledge base emerge and trigger paradigm shifts and reformation. Hype-disappointment-reinvention, for Whooley, highlights long-established cycles of hyped-up clinical approaches that have insufficient empirical evidence to support their wide-reaching promises, followed by a crash brought on by the disappointments to live up to their initial promises.

How do psychiatry, psychology, and the broader psy disciplines scale-up novel care? Whooley writes:

Advocates of change must generate a certain amount of hype for their proposals. Hype engenders the excitement necessary to overcome the status quo. Of central importance to the dynamics of the hype/disappointment cycle is that hype itself can have significant social effects, regardless of whether it is ever realized … By the time expectations come up for assessment, they have already achieved the reforms needed to bring about something akin to the future articulated (even if in a bastardized form). In other words, expectations can accomplish much even if they ultimately disappoint … Sunk costs become justification for staying the new course in the face of growing disappointment… Over time, this hype/disappointment dynamic can damage the credibility and reputation of a field (pp. 17-18).

One of the main tenets of Whooley’s hype-disappointment-reinvention framework is that each crisis-in-care births who he calls “reformers.” Reformers (a term we use here in a merely descriptive way, following Whooley, and not necessarily as a term of endorsement) respond to the uncertainty of treatment disappointments and the disciplinary existential crisis that ensues; they rush in to reinvent the profession.

In today’s socio-political context that surrounds treatment debates and the politicization of transgender medicine, “reformers” are gender-critical organizations, clinicians, and trans-skeptical parents. These reformers began vying to make their presence known by 2016-2018, heels dug into the discourse and clinical debates by the early 2020s. As examples of recent trans medicine reformers, we are talking about gender-critical clinicians and organizations such as the UK’s Clinical Advisory Network on Sex and Gender, which opposes even conducting a clinical trial on puberty blockers to treat gender dysphoria, and Genspect. Genspect advocates for a non-medicalized, talk-therapy approach to gender dysphoria, and they advocate for legal bans on hormonal/surgical treatments for minors and young adults. Genspect USA was involved in organizing “Detrans Awareness Day,” which brought transition regret to the White House along with anti-LGBTQ+ advocacy group The Heritage Foundation.

Hype-disappointment-reinventions in trans medicine

Before the rise of gender-critical resistance to trans medicine, this area of healthcare had already lived through a few reinventions. Its history is complex, marked by early pioneers and periods of suppression (including persecution by the Nazis, as G. Samantha Rosenthal details in this excellent article in The Conversation, which we recommend reading). More recently, it’s being shaped by ongoing, ideological, polarized debates about the scientific evidence, clinical care models, and ethics.

Though today gender-affirming healthcare is seen as a progressive, leftist cause, the ideas and clinical rationales surrounding the biomedical treatment of trans people were rooted in conservative, normative values. Sex change treatment efficacy was sometimes evaluated on the extent to which trans adults became model citizens, married and working. The initial establishment of wider access to these medical treatments, particularly amongst minors, was also accomplished via rhetoric steeped in saneism, anti-disability, and an objective of blending into society’s binary gender roles.

In part due to pressure to produce positive study results showing benefit and to assuage doubts from within medicine, the “old guard” approach to trans medicine for adults was conservative. It involved lengthy pre-treatment psychological assessments and/or talk therapy, ranging from months to years. Assessments were also based on how well the clinician thought the patient could “pass” and be gainfully employed in their new gender role. To gain their doctors’ approval, trans people were expected to adhere to middle-class values and gender stereotypes. For the first few decades, gender identity clinics had a low approval rate for accessing treatments. Estimates vary depending on the study and context, but suggest only a fraction, perhaps somewhere between 1% and 40% of trans adults seeking sex reassignment, were approved.

Similarly, the Dutch protocol, which formalized the medical treatment of gender dysphoria in adolescents, was designed to conservatively identify those likeliest to benefit from biomedical treatments ultimately recommending treatment for about ~40% of patient referrals.

Besides physical attributes, assessments were largely based on mental stability, psychosocial functioning, and the absence of psychiatric issues, like psychosis or personality disorders, which were thought to be signs of “secondary gender dysphoria,” rather than “core transsexualism.” A differential diagnosis was a key feature in initial adult care, as well as in the Dutch protocol for adolescents. Too mad? No history of gender nonconforming behavior or a cross-gender identity in childhood? The old guard gatekeepers would often determine dysphoria was secondary to another condition and patients were rendered not “true transsexuals.” The language of the time reflected this logic of the patient selection process: patients were considered either treatment “eligible” or “rejected,” and “letters of readiness” by mental health professionals determined their fate.

Under the old guard model, colloquially termed “gatekeeping,” detransition, decisional regret, or iatrogenic harm to patients seemed to be extremely rare. Although even past research had limitations (such as high proportions of patients lost to follow-up and divergent operationalizations of “regret”), across several studies in multiple countries, decisional regret and detransition were estimated at between <1-5%.

However, many trans adults felt dehumanized by strict clinical gatekeeping. A majority were denied access to treatments by the psychiatrist/psychologist gatekeepers, while others who made it through their gates felt patronized at the battery of tests and questions about their life history: childhood relationships with parents, traumatic events, gendered and sexual behaviors.

This disappointment spurred reformation and efforts to reinvent adult trans medicine by the early 2000s, and it also formed the basis of the new academic field of Trans Studies, which was built on taking a skeptical position toward psychiatry, of clinical gatekeepers, and disavowing trans madness. This field of scholarship, developed by trans academics and trans advocates, built knowledge based in lived experience, and it critiqued medical power and clinical knowledge produced about gender dysphoria and madness (Awkward-Rich, 2022). As Ian Hacking may say, trans people ultimately resisted their “knowers,” dismissing status quo assumptions about transsexuality that felt objectifying. From the epistemological/ontological rejection of clinical knowledge, the boundaries of what it meant to be trans were expanded and transformed into a self-identity from the standpoint of transgressing the gender binary, rather than a diagnosis provided by any clinician.

By the late 1990s and into the mid- 2010s, trans people and their allies were organizing for civil rights protections in human rights codes and engaging in advocacy campaigns. Much of this focused on introducing the concept of gender identity (as discrete from sex) into the public lexicon and civil rights protections.

The main trans advocacy objectives of this era were to:

Divorce associations between trans and madness in public and scientific discourse;
Assert a biological framework for understanding transness and the etiology of gender dysphoria (“born this way” and the “wrong body” narratives were popularized); and
Reform the gatekeeping model that involved lengthy psychological assessments and exploration of differential diagnoses to inform treatment decision-making.

These goals were largely accomplished, leading to scaled up access to hormonal and surgical treatments. They ultimately culminated in the gender-affirming medical model of care and de-stigmatized, de-pathologized public conceptualizations of trans people. But these advocacy goals also had trade-offs; they were accomplished via saneism (i.e., discrimination based on perceived or actual madness/neurodivergence) and a project of normalization.

The gender-affirming medical model of care and the evasion of madness

Through the early 2000s to the mid-2010s, proponents of the gender-affirming model of care (including academic and community-led researchers, care providers, parents of trans and gender-variant children, and adult trans patients) aimed to reinvent the field. They challenged and, in many ways, won the battle against the old guard gatekeepers who had previously identified connections between gender dysphoria, distress, madness, and queer sexuality. A clinical transformation and hype for the new model followed.

As an example, apparent “social deviancy” that marks some trans people’s lives (sex work, drug use, HIV/AIDS, poverty, suicidality, and criminal behaviors) could, according to this narrative, be ameliorated by hormones, surgeries, and gender-affirmation. Transition became a panacea, but treatment hype also relied on saneism and common tropes about maladjusted trans people. The most striking examples of this are still observed in rhetoric supporting early medical interventions for trans children.

In the early days of pediatric gender-affirming medical care, physician and medical anthropologist Dr. Sahar Sadjadi conducted multi-site ethnographic research of the first pediatric gender clinics opening up in the United States. She examined the status quo ideas and medical discourse leveraged in favor of puberty blocking drugs for gender-variant children. Sadjadi wrote in 2013:

It could be argued that this striking narrative of the miserable transgender adult, dead or just steps away from death, was tactically and polemically used in the face of resistance from certain factions of the medical establishment that would not succumb to any argument, short of complicity in murder, to endorse this new treatment [puberty blockers]. This narrative is indeed powerful and effective precisely because it hinges upon, and circulates through, the familiar trope of the abject trans person. Such a narrative is currently playing a powerful role in shaping the direction of this clinical field as well as the opinions of clinicians, parents and the general public… preventing the body from developing unwanted secondary sex characteristics saves children from violence, suicide, self-harm, and mental illness at the onset of puberty (which therefore constitutes an emergency) and from violence and discrimination (and in some accounts, unemployment, drug use, prostitution, suicide) which besets non-passing transgender adulthood (p. 257).

Said another way, some of the clinicians who pioneered early medical intervention viewed untreated children and youths as “at risk” of growing up to become visible, nonconforming trans adults with undesirable social and psychological outcomes. To be sure, earlier access to hormonal treatments was inspired by a desire to prevent the suffering that was observed among adult trans patients that was theorized to be caused by social discrimination and body dissatisfaction. Indeed, it was also to affirm gender identity/expression. But clinicians also often viewed these treatments as a promising path to greater social integration under cisheternormative logic.

The early results produced by the Dutch team, formalized via the Dutch protocol by 2014 (following the gatekeeping approach), indeed showed promise. Although the initial cohort was of 70 adolescents, one of whom tragically died from a rare surgical complication, results showed decreased gender dysphoria, improved psychosocial functioning, and low levels of treatment dissatisfaction. Pediatric trans medicine also gave parents a new way to interpret their children’s gender-variant behaviors and identities, to think about their children’s futures, and provided them access to clinical experts who could offer assurance and support. The introduction of the Dutch protocol inspired a cultural transformation, and pediatric trans medicine quickly disseminated into the US, the UK, and elsewhere. However, the diffusion of pediatric trans medicine from the Netherlands into cost-containing, neoliberalized North American healthcare systems has also come with some unanticipated disappointments.

Despite its expansion a persistent finding emerged: even following gender-affirming medical treatment, trans individuals of all ages show mixed results. While many do improve, and countless trans people testify to benefits, improvements in quality of life, and life-saving aspects of treatment, others instead persist with worsening mental health—including suicide, suffering, and distress—compared to the cisgender population. For Awkward-Rich, this is trans maladjustment.

Discrepancy between the hyped-up promises to make well-adjusted citizens out of trans people and the reality contained in many research studies signaled the beginning of the disappointment phase. Reformers began to rush in, again. But the modern reformers wanted to close the gates, not knock them down like the previous resistance to the old school gatekeepers.

Containing trans maladjustment in gender-affirming healthcare

Beginning circa 2018, narratives of detransition and regret, previously less visible, also started to emerge via media reports, legal challenges, and malpractice suits. And even within the field, as explained above, expert clinicians and academics fiercely debated the utility, purpose, and harms of assessing and diagnosing youth prior to medical treatment. Championed initially on low or no regret among children/adolescents, the emergence of detransition among the pediatric population presented a disappointment to the gender-affirming medical model, particularly among young people.

In response, gender-critical actors have mounted pressure, with some groups involved as stakeholders behind the scenes of the methodologically critiqued Cass Review. The Cass Review involved several systematic reviews of evidence for puberty blockers or hormones used to treat gender dysphoria in minors, as well as the practice guidelines supporting the gender-affirming care model’s effectiveness. These reviews concluded that evidence demonstrating improved psychosocial functioning was of low or moderate quality and difficult to interpret due to study design issues and other methodological flaws. In these debates, evidence-based medicine (EBM) is wielded as a tool of power by gender-critical reformers to call attention to the uncertain benefits of treatment, but never to acknowledge that a key principle of EBM also includes respect for patient values and preferences—even when a treatment’s evidence base is limited. Still, many trans people would ultimately choose autonomy, accepting some uncertainties and medical risk to feel more at ease in their bodies and in society.

This confluence of factors, promulgated by gender-critical, anti-trans, and socially conservative forces, has again prompted another tweak in the scientific and public discourse within the field of gender-affirming care and trans medicine. Only more recently have some Trans Studies scholars and activists begun to more critically examine the consequences and underlying assumptions of the mainstream trans-affirming discourses fostered during the gender-affirmative hype and normalization era: “what if the goal of treatment ought not to be improvements in psychosocial functioning, but of body alignment or of facilitating embodiment goals?”

Some scholars, ethicists, and clinicians have begun to interrogate the initial objectives and evaluation of transition treatments:

Is mental wellness a necessary or even desirable endpoint for all trans people, particularly those who face challenges functioning in a world not designed for, and increasingly punishes, gender-diversity?;
What if gender dysphoria, neurodivergence, and madness are intertwined in ways the gender-affirming model could never fully recognize?

More crucially: what if the treatments themselves and the gender-affirming model, while helpful for many, sometimes introduce new forms of iatrogenic maladjustment?

At this juncture, the field of academic trans medicine does not have a broad consensus on how to define positive or negative outcomes on which to base evaluation of its outcomes. In our view, greater conceptual clarity, philosophical, and ethical dimensions pertaining to treatments would help to complement the rights-based, autonomy framework that currently organizes clinical conditions. Greater clarity will also help us to interpret and care for detransitioning people, arguably a new patient group who present the field with questions that warrant evidence-informed answers.

In a way, trans maladjustment and madness are beginning to be embraced by Trans Studies and trans medicine when they were long disavowed. Leveraging a “trans negativity” theoretical lens, Oosthoek et al. (including child and adolescent psychiatrist, Dr. Annelou de Vries, who was among the pioneers of the Dutch Protocol) wrote in 2024 in BMC Medical Ethics:

Trans negativity challenges the dominant discourse that GAMT [gender-affirming medical treatments] must necessarily alleviate distress and lead to improvement in overall well-being and functioning in order to be justified, instead acknowledging that negative feelings often persist after, or even because of, GAMT. As Malatino states, ‘trans negativity challenges the dominant framing of GAMT characterized by a period of distress, followed by an “experience of harmony, good feeling, corporeal comfort, and ease when navigating everyday social interactions.’ In other words, while narratives of improvement can function to justify GAMT, they risk excluding more nuanced and complex experiences. Trans scholars argue that experiences of GAMT are often messier, more ambivalent, and temporally more complex than the binary of ‘doing bad before GAMT” and “doing better after GAMT’.

We in our own research studies see not only trans maladjustment but also detrans maladjustment caused by treatment outcomes themselves. That is, iatrogenic gender dysphoria or what some detransitioners refer to as “reverse dysphoria.” This emergence within the iatrogenic age reflects a growing recognition of complexity and potential disappointments built up after more than a decade of hype that has indeed brought much trans joy and civil rights, but also some unexpected letdowns.

Transed and detransed by the hype of gender-affirmation

Both madness and transness can be painful and immersive experiences. Perhaps the trans tipping point in the mid-2010s provided some mad people in certain cultural milieus respite—a transition toward normalization, blending in, masking. Trans medicine’s broad reinvention to the gender-affirming medical model, and the cultural transformation that followed, promised a path to self-actualization, happiness, and authenticity. It made access to hormones/surgeries possible for some people who would have undoubtedly been rejected by many of the old guard gatekeepers.

Highlighting trans-affirmation of the mid-2010s, Ambrose Kirby wrote in the Routledge International Handbook of Critical Mental Health:

While our identities are being normalized, our resistance to transphobia is increasingly being separated out from our identities and pathologized. Instead of being trans people who creatively survive transphobia, we are trans people with anxiety disorders, anger disorders, bipolar, schizophrenia. Our basic identities are less and less considered a ‘mental illness,’ but our strategies for surviving are being taken out of context.

What Kirby did not consider at that time, but cannot go unaddressed today in the context of detransition, is that transition for some people is survival. It’s a way to cope, it provides access to community in an otherwise isolated world, a stepwise process to reinvent oneself, to manage distress and anxiety, to contain bad feelings. Whether this could be viewed as adaptive or maladaptive, can and should be debated especially if regret and a gender identity change arises post-treatment.

Detransition is relatively uncommon and there are many who detransition feeling grateful for the opportunity to explore their gender, or because life as a trans person can be difficult. But other factors often drive detransition, such as persistent bad feelings like what Awkward-Rich describes as maladjustment. Like how antidepressants can amplify suicidality, for some people, the hormonal/surgical treatments perhaps never fully relieved gender dysphoria, or worsened it—the dysphoria endlessly moving to new parts of the body after each cascading intervention.

And now, these disappointments and unexpected outcomes are being exploited by a new generation of gender care reformers.

Realizing there are some limits in the evidence base for pediatric trans medicine, some detransitioners and other LGBTQ+ people skeptical of the biomedical treatment hype have joined the gender critical movement to put restrictions on it. In this complex political moment, detransitioners and even a few trans adults have testified in favor of restricting pediatric trans medicine, feeling aggrieved and seeking to reform the medical system they feel caused them harm. Others champion psychotherapy as a “first-line treatment”—without really contending with the fact that psychotherapy and other psychological interventions for gender dysphoria also still lack, in many cases, a strong empirical evidence base. Some forms of psychotherapy have even contributed to harm among LGBTQ+ populations.

And so another hype-disappointment-reinvention cycle is now underway, this time spurred by the emergence of anti-trans politics, and stories of detransition/regret from former trans youth who grew up to become detrans young adults. Most seem to be young women, bisexual or lesbians, nonbinary, gender-fluid and nonconforming folks, many of whom also affirm mad, neurodivergent, or disabled identities. Their testimonies, though, are frequently ignored by the Left and marshalled by the Right.

“Whose suffering has been systematically ignored, and what finally led to the recognition of that suffering?,” asks sociologist Arthur W. Frank.

Conclusion: Cycles of uncertainty and the politics of treating gender

According to Whooley, within periods of reinvention, new hopes are introduced by reformers and “new organizations are created” (p. 15). In the current period, we see gender critical organizations such as Genspect, the Clinical Advisory Network on Sex and Gender, Sex Matters, and even the Cass Review as indicators of this reinvention. Many in these camps advocate for psychotherapy as a treatment for gender dysphoria, with some actively campaigning against any further research into biomedical treatments such as puberty blockers.

The nature and permanence of future reinventions is highly uncertain. It is unclear whether clinical consensus will change lastingly, when the politicized debates will die down, or what the approach to trans medical care (particularly for minors) might look like in 5-10 years. It could restrict further, or it could expand. Even if more gender critical and socially conservative forces were to become dominant, it remains to be seen what exactly would unfold. Regardless, restrictions on care and defunding of LGBTQ+ and trans care research in the US are immediate signs of a paradigm shift and, to many, strong indicators of authoritarianism and anti-science.

Whooley’s hype-disappointment-reinvention framework provides a powerful lens for understanding the trajectory of trans medicine and its intersections with madness. We have traced how the initial conservative “gatekeeping” model, after being criticized for its rigidity and pathologization of trans adults (a source of disappointment), was replaced by the gender-affirming medical mode, fueled by clinical hype, saneism, and anti-disability rhetoric that ushered in ideas of liberation, normalization, and social integration. But about a decade later, this model applied to young people is facing its own disappointment phase, with the instrumentalization of research showing persistent distress, neurodivergence, detransition, and regret—unexpected outcomes according to its initial promises.

This disappointment, in turn, is fueling a new phase of reinvention, led by “reformers” who stoke uncertainty surrounding biomedical treatments for gender dysphoria. They propose alternative approaches—often reminiscent of older gatekeeping models or centering psychological interventions whose efficacy for gender dysphoria is unproven. As Whooley points out, these reinventions are often “driven less by developments in knowledge, and more by a desire to mitigate the deleterious consequences of its [past] ignorance” (p. 15).

Whooley’s cycle also warns us that the new reformers, like those they criticize, may generate their own hype.