The authors situate their argument against a backdrop of dramatic epidemiological change. Population surveys published between 2008 and 2019 estimate that 0.3 to 0.5 percent of adults and 1.2 to 2.7 percent of children and adolescents identify as transgender, with consistent upward temporal trends across countries. Referrals to specialist pediatric gender services tell an even starker story: a systematic review covering 11 countries found referral rates below roughly 2 per 100,000 young people in 2010, rising to between 6 and 18 per 100,000 by the mid-2010s. At the Amsterdam clinic, adolescent referrals climbed from fewer than 20 in 2000 to around 230 in 2016. The composition of the referred population has also shifted, with the growth driven primarily by adolescent natal females, many with peri-pubertal onset of gender dysphoria, and with high rates of psychiatric and neurodevelopmental comorbidity. A Finnish register study found psychiatric morbidity in 48 percent of adolescents referred between 2011 and 2019, compared with 24 percent before 2011.

Why these numbers rose so sharply remains contested, with proposed explanations ranging from social and peer influence to increased awareness, positive publicity about gender-affirming treatment, and reduced stigma. What is less disputed is how the clinical model changed. Over the past three decades, the gender-affirmative approach—affirming a stated gender identity and offering hormonal and surgical interventions to align the body with it—became the dominant paradigm, endorsed by influential guidelines such as those of the World Professional Association for Transgender Health. Simultaneously, many services moved away from rigorous mental health assessment and strict eligibility criteria, which some advocates framed as unethical gatekeeping. The Dutch protocol that pioneered medical intervention in adolescents originally demanded childhood-onset dysphoria, persistence into adolescence, a supportive environment, absence of serious psychiatric comorbidity, and minimum age thresholds; several of those safeguards, including the childhood-onset criterion, were later dropped from Dutch guidance and are absent from WPATH’s 2022 standards.

Against this shifting landscape, the authors review what is known about detransition—generally defined as stopping or reversing the social, medical, or administrative changes achieved during a gender transition, partially or completely, temporarily or permanently. Prevalence estimates vary widely because of methodological flaws and inconsistent definitions, but a critical review estimated that discontinuation of hormonal medication ranges from 1.9 to 30 percent, with detransition and regret after hormonal treatment ranging from 0 to 10 percent and after surgery from 0 to 2.4 percent. A recent latent class analysis of 957 detransitioned people in the United States and Canada identified four distinct subgroups, only one of which—roughly a third of participants—combined changed gender identity with moderately high regret. The authors stress that most patients do not regret their treatment and that their analysis deliberately excludes positive experiences, focusing solely on the distressed minority.

The conceptual core of the paper is the argument that, for some of these patients, the treatment itself can constitute a traumatic event under DSM-5-TR criteria. The manual requires exposure to actual or threatened death or serious injury, and the authors contend that irreversible physical sequelae of gender-affirming treatment can meet this threshold when viewed through the lens of a patient who has reidentified with their natal sex. These sequelae include both anticipated effects—sterility after gonadectomy, loss of sexual function after vaginoplasty, loss of breastfeeding capacity after mastectomy, voice deepening and male-pattern alopecia with testosterone, breast growth and testicular atrophy with estrogen—and surgical complications such as urinary incontinence, sexual dysfunction, and thromboembolism. For a young person confronting the permanence of these changes, the authors suggest, the injury may be experienced as catastrophic, generating horror, helplessness, anguish, self-disgust, betrayal, rage, guilt, and shame.

Whether such a presentation qualifies as PTSD depends on the full diagnostic picture. The DSM-5-TR requires symptoms from four clusters: intrusive memories, dreams, or dissociative reactions; persistent avoidance of trauma-related reminders; negative alterations in cognition and mood, such as persistent self-blame or distorted beliefs about oneself and the world; and alterations in arousal and reactivity, including hypervigilance, irritability, and sleep disturbance. Symptoms must persist beyond a month, cause clinically significant distress or impairment, and not be attributable to substances or another medical condition. The authors anticipate two objections. First, critics may argue that patients who did not experience the treatment as traumatic at the time cannot later develop PTSD—but the DSM-5-TR explicitly recognizes delayed expression, sometimes emerging years after the event, and the modern criteria no longer require intense peri-traumatic fear. Second, some may argue that consent negates trauma; the authors counter with the observation that a soldier who voluntarily enlists can still develop PTSD, quoting the psychoanalyst Caroline Garland’s remark that an event may be no less traumatic because it was sought out.

To illustrate how attitudes toward a bodily intervention can transform retroactively, the authors draw a carefully hedged parallel with female genital mutilation or cutting. They are explicit that they are not equating the two practices. Rather, they invoke research showing that some women who underwent FGM/C in childhood felt no trauma at the time but developed PTSD symptoms after leaving their cultural context and reinterpreting the procedure through a new framework of belief—a process described as hitting bottom, in which pride and honor give way to shame and mourning. Some detransitioners, the authors propose, undergo an analogous reversal: once embedded in communities that celebrated their transition and praised by their clinicians, they later come to see themselves as people subjected to injurious procedures that damaged fertility or sexual function. Some also report harassment and ostracism from both trans communities and gender clinicians after speaking out, a phenomenon the literature terms detransphobia.

The second pillar of the paper is moral injury, a concept originating in studies of Vietnam War veterans and defined in its original form as a betrayal of what is right, by someone who holds legitimate authority, in a high-stakes situation. In September 2025, the American Psychiatric Association incorporated moral problems into the DSM-5-TR under code Z65.8, expanding the former Religious or Spiritual Problem category so clinicians can now flag moral dilemmas, distress, and injury—experiences that disrupt a person’s sense of right and wrong or their sense of goodness concerning themselves, others, or institutions. The code can stand alone or accompany diagnoses such as PTSD or depression. The authors argue this framework maps closely onto some detransition narratives: patients may feel betrayed by the clinicians who provided treatment, by the profession that regulated it, or by institutions that promoted it, and may experience guilt, shame, loss of trust, and inability to forgive. Notably, the DSM-5-TR itself notes that trauma inflicted by trusted caregivers heightens both the risk and severity of PTSD, and research suggests PTSD complicated by moral injury is harder to treat unless the moral component is explicitly addressed.

The paper closes with clinical and scientific implications rather than treatment protocols, which the authors defer to future work. They note that ICD-11 offers a broader definition of traumatic events and a distinct complex PTSD category requiring severe affect dysregulation, negative self-concept, and interpersonal difficulties, and that when full PTSD criteria are unmet, a specified trauma- and stressor-related disorder may apply. Recovery, they suggest, likely requires more than psychotherapy: acknowledgment of the injury, community understanding and reintegration, shared responsibility, and, for some, social action or legal accountability—a survivor mission that trauma research has linked to resolution. The authors also urge clinicians to examine their own cognitive biases, noting that interventions endorsed by eminent organizations may be assumed to be uniformly beneficial, that misinformation and censorship affect the field, and that high-quality guidelines from Scandinavian health authorities actually recommend psychotherapy and psychosocial support as the primary approach for minors. Above all, they argue, detransitioned people who have shared their stories deserve recognition for drawing attention to a form of iatrogenic harm that, on their account, psychiatry now has the diagnostic vocabulary to name—and the obligation to study.

Subject of Research: Posttraumatic stress disorder and moral injury among individuals who detransition after gender-affirming medical treatment

Article Title: Detransition, Posttraumatic Stress Disorder, and Moral Injury

Article References: Clayton, A., & McDeavitt, K. (2026). Detransition, Posttraumatic Stress Disorder, and Moral Injury. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-026-03669-x

Image Credits: AI Generated

DOI: 10.1007/s10508-026-03669-x

Keywords: detransition, posttraumatic stress disorder, moral injury, gender-affirming treatment, gender dysphoria, DSM-5-TR, trauma, iatrogenic harm, informed consent, pediatric gender medicine, Archives of Sexual Behavior, mental health