Interview with A: On Detransition, Obsessive Thoughts, and "Really Trans"

This is an interview with A, a 30-year-old detransitioned woman in the Bay Area. She agreed to answer some questions about detransition, her experiences in therapy, and what she has learned. This interview touches on some really important stuff: the difficulties in knowing if you’re “really trans,” how therapists may be highly trained in some areas but be clueless when gender dysphoria is involved, and how to pick up the pieces and get better after a complicated time in your life. Thank you, A, for your generosity in sharing your story.

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Could you talk a little bit about what was going on in your life when you transitioned? 

When I was 22, the BDSM community was my entire social circle. I didn’t have great boundaries as a young person, and I would do things sexually that made me uncomfortable because I didn’t want to be rude or sex-negative. At the time I was reading a lot of Dan Savage and sex-positive blogs, so being sexually liberated was really important to me. I saw the men in the kink community getting to do what they liked, while the women were constantly creeped on. 

At the same time (2012), trans was becoming visible on the blogs I read. I read articles like “The Null HypotheCis” that made me think non-trans people don’t question their gender. The more I read about it, the more I thought about it, and I eventually decided I was probably trans since I had thought about it so much. However, I didn't initially plan to transition since I couldn't imagine coming out to my family and disrupting my life.

Six months later, I moved to the Bay Area for work. I didn’t know anyone, and I started dating someone I met on OkCupid. We smoked a lot of weed and both fell behind at our new jobs. They had a mental health crisis and started transitioning to female. I had worsening anxiety and got diagnosed with OCD and put on a high dose of Zoloft. It was not a great time for me to make a big decision like starting hormones, but I was feeling brave and reckless. I started T at 23, about a year after I first identified as trans.

So it sounds like you were in an exploratory phase of your life, and not in the most secure situation. How did transitioning go for you: did it meet your expectations? What was challenging?

Transition was exciting at first. I felt like I was choosing my own destiny in a way I hadn't been able to before. I had never gotten a tattoo or piercing, so taking T was a huge leap for me. I enjoyed the initial physical changes on T, and I felt more confident hooking up with strangers as a "man" than I had as a woman. So it probably prolonged my wild-early-20s phase by six or nine months.

My physical results were okay. After top surgery and a couple of years on T, I passed for male about 80% of the time. If I hadn't been living in the Bay Area, I probably could have passed more often.

Transition ultimately didn't work for me because I wasn't willing to either hide my past or spend a lot of time explaining my trans status to acquaintances. Trying to interact with others as a man made me socially awkward. I worried about whether the person I was talking to saw me as a man. I worried I was making people uncomfortable. I couldn’t tell stories about my past, in case they confused people about my gender. I felt like I was pretending to be someone I wasn't, and I became less social and less confident as a result. 

I know some trans people who have solved this by being super-out and telling everyone they meet their pronouns, but that’s not who I am. I like the attention to stay focused on ideas, the task at hand, or other people’s problems, not my feelings about my gender identity.

After almost four years on T, I had to face that living as a man did not feel authentic. I ran out of T and didn't get it refilled, and then I gradually stopped identifying as trans at all.

You mentioned some other mental health struggles you were dealing with at the same time you were transitioning: anxiety and OCD. Do you have any perspectives on the relationship between your OCD and gender dysphoria?

My initial thoughts I was trans definitely had an obsessive flavor. There was a period of time before I decided to transition where I spent hours writing thoughts about my gender into 750words.com, trying to figure out whether I was trans or not. I believed only trans people ever question their gender identities--so if I spent a significant amount of time thinking about it, I must be trans. 

This argument--the Null HypotheCis argument--is the opposite of what you learn in cognitive therapy for OCD. Cognitive therapy tells you that you can’t control your thoughts, and they don’t define who you are. In fact, OCD obsessions are often thoughts that are the most incongruous with the self--for example, I volunteered at a rape crisis hotline, and during that time I worried that I had somehow sexually assaulted someone. So that article was exactly the wrong one for me to come across at the time.

When I started therapy, trans wasn't my primary obsession. My biggest fear was I would spontaneously commit suicide or attack someone else. My therapist was an OCD specialist, but I'm not sure if she knew trans OCD existed. I wonder if my initial obsessions had been about trans themes--would she have recognized it, or would I still have transitioned?

What could your therapist have done better?

Although my therapist gave me a comprehensive assessment when I came in thinking I may have OCD, she asked me very few questions when I said I wanted to transition. I think she didn't want to be on the wrong side of the issue. She told me I should try it if I thought it would make me happy, and she asked me if I had been gender-nonconforming in childhood. I told her I liked books and computers and in kindergarten didn't feel like I was really either a girl or a boy. She wrote me a letter saying I had been gender dysphoric since childhood and had been living as a man for a year--neither of those were true, but that's what we thought an endocrinologist would want to hear.

I wish she had taken the time to dig into my desire to transition, rather than rushing to affirm my identity. I was unhappy and had gender dysphoria--I definitely could have used the help--but medical transition was treated as a quick fix. I wish she had encouraged me to continue working on my OCD and addressing the lifestyle factors that were causing my anxiety, and reminded me that medical transition would still be there in six months or a year. I wish my therapist or my psychiatrist had looked at my shitty relationship (my partner at the time came to some of my appointments and talked more than I did) and asked me about it, rather than being weirded out or assuming that's just what trans relationships are like, or whatever reason they let those red flags go.

In the end, my life got better not because of transition, but because I got out of that relationship, started putting effort into work and other things I cared about, and stopped having sex with strangers. In the years since my transition, I’ve learned that my anxiety spikes when things are going wrong in my life, and there were a lot of lifestyle changes I should have tried before medical transition. I wish my therapist had looked at my whole life when I said I wanted to transition.

It’s striking that your therapist lied for you in a letter to a doctor. Have you continued to see her? Did you ever discuss your detransition with her? What is your intuition on why a therapist would practice in this way?

I stopped seeing her pretty soon after that, and I haven't been back in therapy since. A month or two after I started T, she told me if transition was making me feel better, I didn't need to come in anymore, so I didn't. 

Overall, I don't think she was a bad person. I think she was just a nice liberal lady in the Bay Area who didn't know a lot about transgenderism. At the time there was even less information available about detransition and the different reasons people can experience gender dysphoria, so I don't fully blame her for not knowing--but I do think that as a community, we need to get the word out that medical transition is more complicated than "if you say you're trans, you are".

I actually did talk to my current doctor about my detransition, because I needed a doctor's note to change my passport and Social Security record back from M to F. She works at a big primary care clinic now, and previously worked for a major informed consent clinic in SF. I told her I had made other lifestyle changes that addressed my unhappiness, and I no longer felt I needed to be a man. She was totally willing to give me the letter, although she definitely thinks I’m genderfluid now. She said I was the first patient she'd ever had who wanted to change an ID back, but she did not believe she should be an impediment to how anyone identifies.

Did you have any mental/physical health difficulties going off of testosterone or post-surgery?

Quitting T actually improved my health. While I was on T I had high cholesterol and prehypertension (to be fair, I ate a lot of takeout and didn't work out, but the numbers did look better immediately after I went off T and before I made any lifestyle changes.) I would also get intense cramps--those have thankfully gone away as well.

I didn't have any serious complications from surgery, but the sides of my chest are still numb and my nipples are slowly scarring over. (I had no idea nipple grafts can shrink as your body heals, but anecdotally I've heard this isn't uncommon.) This is my biggest regret about my transition. Touch on my chest never did much for me sexually, so I didn’t think I would care, but any touch on my chest feels weird now.

What has been helpful for your mental and physical health while detransitioning? What has been good, what has been hard about the process?

Starting an exercise routine has been great for me. It sounds silly, but one of my almost-daily routines is a hot yoga class in front of a mirror. Spending an hour a day looking at myself as I sweat and struggle with something has been grounding. It has helped me accept how I look, and seeing myself slowly get stronger is a great reminder of how change happens over time.

Detransitioning has been humbling. In my mid-20s, I got too far into a weird idea I found online and had my breasts surgically removed, and I’ll always have to live with that. It really rocked my confidence for awhile--how can I trust my judgment in other areas if I got this one so wrong? Ultimately, I drastically reduced the time I spent online and how much I identified with the things I was reading there. I also quit the kink community and spent more time on non-gendered, non-sexual aspects of my life. I played competitive chess intensely for a couple of years, and now I am focusing on my career and part-time grad school. I think what I really needed was something to do and a community that valued me.

That’s something I have heard from a lot of people who have dealt with gender dysphoria - trans or detrans - it’s just helpful to take the obsessive focus off gender and concentrate on health and mental balance. What kinds of advice would you give to someone who is not sure if transition is right for them?

Take a break from reading or watching trans stuff on the internet before you make any permanent changes. It's easy to think transition makes sense in the abstract, when you're by yourself on your phone or computer. Try immersing yourself in non-gender-related activities and see if transition is still as important to you once gender is not at the forefront of your attention.

Let go of trying to figure out if you're "really trans" or not. Even assuming there is such a thing as "really trans", whether you are or not is unknowable. In my view, you should transition if you'd prefer to live as a trans man than as a woman. (Or, you know, fill in your identity.) Ultimately, the choice you have to make is how you want to live in the world. 

If you're considering top surgery, even if you don't care about having sexual sensation in your chest, consider surgeries that prioritize saving nerves over surgeries that give you the flattest or most male-looking chest. It's not just about whether you enjoy having your nipples played with--any touch on your chest may feel bad after surgery.

What kind of advice would you give doctors and therapists to best help patients like yourself, either before transition or during detransition?

Consider the whole person, not just the gender dysphoria. I spent a lot of time in therapy in my late teens and early 20s, trying to get a handle on why my life made me sad and anxious. It turned out that I needed more sleep, fewer sexual partners, and something to do that’s unrelated to my gender presentation or sexuality. Don’t assume that gender dysphoria is at the root of your client’s mental health problems.

If you are going to give people access to hormones and surgery, please do your research on the variety of outcomes people can have with medical transition. Some people go on T and stay happily transitioned for life. Some people go on T and stay happily transitioned, but need repeated surgeries to correct complications of their earlier surgeries. Some people quit T and detransition or stay transitioned. It's not true that anyone who thinks they should take hormones or have surgery will be happy with that decision in 5, 10, or 15 years.