Introduction

Gender-affirming surgery (GAS), an intervention to align patients’ physical appearance with their gender identity, is sought to resolve gender dysphoria (GD) and improve quality of life (QoL). While many studies have documented positive results with GAS, (Eftekhar Ardebili et al., 2020; Lindqvist et al., 2017; Nobili et al., 2018; Wernick et al., 2019) some have highlighted negative prognoses and regret after GAS. For an unknown minority of patients, GAS does not alleviate GD but instead exacerbates distress, which ultimately leads to regret of the decision to have undergone surgery and, occasionally, detransition interventions. Common risk factors of regret include poor family/social support, late-onset gender transition, and poor sexual and mental health (Bustos et al., 2021; Landén et al., 1998; Narayan et al., 2021). A current review on studies which mostly utilized questionnaires reported that regret after transfeminine interventions stands at around 1%, and that after vaginoplasty at 2% (Bustos et al., 2021). Studies have also defined and categorized regret based on degrees of severity, persistency, and etiologies. Pfäfflin (1993) classified regret into major and minor regret, and Kuiper and Cohen-Kettenis (1998) classified it as “clear regret,” “uncertain regret,” and “regret assumed by others.” Major regret is defined as the emergence of dysphoria secondary to the new appearance or desire to detransition, thus challenging the benefit of GAS. While minor regret can be commonly seen due to general life nuisances, it is transient and rarely impacts the lives of these patients. Wiepjes et al. (2018) and Narayan et al. (2021), on the other hand, categorized regret as “true regret,” “social regret,” “medical regret,” and “feeling non-binary.” True regret indicates how patients thought GAS would be a “solution” for, for example, homosexuality or personal acceptance issues, but, in retrospect, regretted the diagnosis and treatment. Whatever the cause of regret is, both Kuiper and Cohen-Kettenis (1998) as well as Lawrence (2003) agree that measurements of “regret,” ultimately, represent the subjective experience of regret and that, although rare, individual cases of regret should be examined as they are a major clinical issue involving physical, psychological, and social distress (Dhejne et al., 2011).

Here, we report on the first reported case of regret after GAS in Taiwan. The aim of this report is to explore determinants of regret and navigate through the complexity of GD. Furthermore, assisting health professionals to identify regret, providing tailored care, and helping people ease into their new gender identity is very crucial, as individuals that experience regret are much more vulnerable and often “silent” in less socially tolerant Asian cultures (Winter, 2009; Withers, 2020). We hope this case can encourage health professionals and empower patients to speak up for themselves.

The material presented here was derived from: (1) a semi-structured, storytelling-based interview (Jamshed, 2014) and (2) follow-up interviews when the analysis of the first interview revealed regret. The patient’s narratives were analyzed by noting significant life events and arranged chronologically. During the analysis, information was simultaneously confirmed with the patient, and she gave written informed consent to the publication of this report.

Mei’s Story

Childhood

Mei was born in the 1980s to a Hakka family as the youngest child. Her birth father was involved in gambling and prostitution. He also committed domestic violence.Footnote 1 In view of her parents’ difficult financial situation, her grandmother suggested that Mei be given over to her birth mother’s brother, her uncle, for adoption. Her new family did not have any sons, and she therefore became their only son. However, her adoptive father did not accept this new addition to the family and neglected her.

“My mom told me that my father never hugged me. From the moment I came to his household, no matter what I did, I was an eyesore for my father. From a young age, I knew my father didn't like me.”

Mei soon believed that being the only son was the reason why she struggled to please her father. In addition, according to the Hakka people’s traditional values, men are meant to take responsibility of the family and are first in line to inherit the family fortune, which strengthened her father’s dislike of her.

“When I was very young, I felt that being a boy was a heavy burden. I thought that I was given over to my parents because I was a boy. They told me that I was there to ‘carry on the family line’ and I understood that as my purpose in this family. I really disliked this feeling. Being a boy was painful for me.”

Since Mei was a young child, she was aware that she was different from others. She had a feminine character and spent most of her time playing with other girls. For that, Mei was bullied by her peers and called names. Mei cried whenever her grandmother took her to the barber for haircuts that she deemed too short and ugly. However, she also understood that she could not refuse the haircuts as her grandmother would not be happy about it. Mei was close to her grandmother, whom she spent most of her childhood with and whose opinions mattered a lot to Mei. While she learned about Thai ladyboys from watching TV, which sparked her interest in exploring her own gender identity and GAS, she also understood her grandma’s stance on transgender people, as she called them “ying-yang people” (a pejorative term for intersex people).Footnote 2

Adolescence (13–22 Years of Age)

Mei was a well-behaved teenager and never caused trouble for her family or her teachers. She excelled academically, was admitted to one of the best all-boy high schools, and later on made her way into a highly ranked law school. During high school, she had a relationship with a boy who was, in fact, heterosexual. She was attracted to her male counterparts and in the relationship, Mei considered herself a heterosexual woman. She and her boyfriend once made plans to save up money together to pay for her transition. However, when Mei and her boyfriend went to different universities, their relationship began to fray as her boyfriend started to reciprocate attention from other girls. The instability and capriciousness of their relationship caused Mei to become anxious and depressed. When Mei turned 18, at her college roommate’s encouragement, she visited a psychiatrist for the first time. Besides being prescribed antidepression medication and undergoing therapy sessions, Mei talked to the psychiatrist about her gender incongruence and asked for feminizing hormones. The request was rejected by the psychiatrist who told her to seek help elsewhere. Mei started taking the anti-depressant drugs but stopped within a week, because they made her drowsy and she was worried about the long-term effects. Mei then visited a local pharmacy to get Premarin tablets on her own. However, she soon stopped taking the drug because it caused her abdominal pain while causing swelling and bloating in her face. Apart from the discomfort, Mei feared that changes in her physical appearance would raise suspicion from her family.

Upon turning 22, Mei started to notice prominent physical changes to her body and appearance. As she matured into a more masculine form, her anxiety and agony increased. However, she did not grow out her hair nor dress in female attire, as she knew her Hakka grandmother would not approve of it. At the same time, Mei and her boyfriend finally broke up.

“He told me, 'You aren't even a real girl.' What he said really crushed me.”

Mei had thought she was safe and accepted in her first relationship, but it ended with denying her of her gender identity. She felt hurt, traumatized, and stuck. She hated her life situation and knew she needed to make changes. Along with the immense pressure law school inflicted on her during exam season, her depression intensified.

Adulthood (Post-Graduation: 2009, 23 Years and Older)

After graduating from law school, Mei started applying for jobs, which proved to be quite easy with her splendid academic background. The problem was staying in a job: none of her employments lasted for more than 4 months, leading to her to struggle financially. Mei felt that she could not adapt to her work environment or society in a male role.

“I couldn't adjust to my jobs in the role of a man. There was a long period when I wasn't even able to afford the premium of my national health insurance.”

In 2013, Mei received her first diagnosis of gender identity disorder according to the DSM-IV. During that time, Mei could not afford gender transition. She therefore decided to fly to Australia to work and save up for surgery. There, she felt free; she was happier than ever. But when offered an opportunity to stay in Australia, Mei declined, since she had set her mind to eventually return to Taiwan, undergo surgery, and start a new life.

“I was very anxious at the time. For me, 30 years of age is a checkpoint in life, especially when you realize your classmates have gotten married, have kids, or some even started their own law firms—and I was still sorting out my life.”

As Mei turned 30, she became extremely anxious and restless. People around her seemed to move on with their lives and started families or their own law firms while she was still figuring out the basics of life: her gender identity. In 2016, after returning to Taiwan, Mei approached another psychiatrist for her second clinical diagnosis. Within a year, she received her second diagnosis of gender dysphoria based on the DSM-5. This time, the psychiatrist agreed to give her feminizing hormones on the condition that both her parents came to the clinic with her. This was the first time Mei told her parents about her plan to transition. Neither of them was particularly supportive but Mei’s mother agreed to accompany her and she successfully obtained feminizing hormones. However, it was not until April 2017 that she took her first pill. Prior to that, Mei had consulted a sperm bank and twice had undergone sperm cryopreservation. She had long reflected on her identity as the only grandson of her family and on the fact that she will forever have the responsibility to pass on her heritage. Her devotion to her family values and especially her grandmother’s opinions still had a large influence on her.

“She (Mei’s grandmother) was very kind to me and that’s why I felt extra guilty. I didn’t want her to see my transformation and hurt her. This made it even more difficult. I couldn’t even grow out my hair… She passed away at 97 years old. At the time I had a really scary thought. I would look at her and think in the back of my mind, ‘I really don't know when you’ll die so I can start making changes for myself.’ I really wanted to die. The thought of committing suicide never left my mind…only when she passed away did I start hormone treatments.”

After 8 months of HRT, in December 2017, Mei underwent GAS at the age of 31 years. Physically, postoperative care was painful, consisting of continuous douching and dilating. Mentally, at one point, Mei lost sense of her gender identity. She could not tell if she was a man or a woman; she felt like she was a “neutered cat.” This continued for the first 3 months post operation. Then, as the wound healed and the pain subsided, Mei realized she had sexual urges but could not relieve them when she tried to satisfy herself.

“When I had sexual urges, it felt as if there was a flood within me but no sluice gate. Having sexual desires was very painful for me. The physical pain and mental devastation are things someone who has not undergone surgery would never understand.”

Soon, another feeling took over: regret.

“All my life, I had wanted to do [GAS]. But when I got it, when I knew what it really is, it was unbearable to accept or deal with…I never thought that I would regret this.”

For a long while, Mei was afraid to touch her lower body. Initially, it was due to the pain. Then, it was because in its place, she felt there was something “fake.” At that point, she broke down.

“…this so called 'vagina' isn't really a reconstructed vagina: It's merely a pouch, like the ones kangaroos have. I've simply drilled a hole in my body.”

Mei could not understand why after longing for surgery since she was young, she now regretted her decision. She felt that she was a woman trapped in a body that represented neither a man nor a woman.

“I hit rock bottom. I kept wondering why I was still in pain; I thought things would become better, but they didn’t. Before the surgery, I was in so much pain, I didn’t feel human; now that I’d completed the surgery, the pain didn’t end. It felt like life was pointless and all the effort I’d made was for nothing. I’d given it all to reach my goal but it all seemed like a big joke.”

Follow-up

We approached Mei in 2021 to talk about her transition journey and how she was doing 3 years after the surgery. Her sense of regret was still strong but she was learning to adapt to her situation and accept her body. There were moments in her life when self-acceptance was not enough to overcome the struggles she had. First and foremost, Mei could not enjoy sexual intercourse. She felt that during sex, she was acting out a woman’s role instead of actually being a woman. Her negative sexual experiences and her loss of a way to release sexual tension really bothered her. Another issue Mei struggled with was the fear of being exposed. As she could not internalize the results of the surgery as her own body, the surgery had not completely removed her sense of body uneasiness or her GD. After changing her ID, she felt even more apprehensive about being revealed as neither woman nor man. This left her wanting more feminizing procedures on top of her breast augmentation, such as a forehead augmentation and a jaw reconstruction. In addition, her anxiety took a toll on her romantic relationships, which further exacerbated her feelings of defeat and regret. On the other hand, when she visited her Hakka community, she would purposely dress up as a man. Her village was small and closely-knit; therefore, every time she returned home, she would change her attire to prevent attracting unwanted attention to not only her but more so to her family. Nevertheless, Mei also mentioned some positive changes such as having a better relationship with herself and an improved work experience. After the surgery and the ID change, Mei gained more confidence and eased into her new female gender role, despite rejecting some of her bodily changes. She has been working as an insurance sales agent for almost 1.5 years now, which is the longest duration she has ever stayed in one job. Mei found it easier to adapt to her coherent female work role. Finally, through all the hardship she went through, Mei believes she has become a stronger person.

Discussion

Mei was a textbook candidate for GAS, not only fulfilling all criteria for GAS but also possessing protective factors against regret, such as greater childhood femininity and younger age at first wish to change sex (Lawrence, 2003). The surgery was something Mei yearned for since she was young and had spent years saving up for. Therefore, when she realized the surgery and its outcomes were not what she had expected, she was devastated. Mei’s experience aligned most with “true regret” and “major regret,” in that she thought gender-affirming treatment would be the solution to her personal acceptance issues and failed relationships, but, in retrospect, she regretted the diagnosis and treatment as her problems worsened, even to an extent of secondary dysphoria (Pfäfflin, 1993; Wiepjes et al., 2018). The intensity of her regret was the result of a build-up of events and realizations. The first such event was when, after several attempts at masturbation, Mei noticed the reduced sexual stimulation, despite the reconstruction of a functional clitoris, leaving her devoid of a sexual outlet. Moreover, the change in sexual experience due to differences in male/female orgasming patterns and the decreased sex drive due to the absence of testosterone was not anticipated by Mei (De Cuypere et al., 2005). Despite the optimal aesthetic appearance and vaginal canal depth, she was not satisfied and could neither find sexual nor dysphoria relief with the reconstructed organ. What followed were unsuccessful romantic pursuits, which Mei truly believed were due to her not being “a true woman” and her inner fear of being exposed as a transgender woman. As compensation, she craved more cosmetic surgeries to improve her physical femininity. Moreover, Mei’s lack of family support and intimacy made her especially vulnerable to this unforeseen regret. Family attunement is crucial to providing strong support for the individual before and after surgery (Fey et al., 2020), which is something yet to be incorporated into transgender healthcare in Taiwan. Finally, with regret being the feeling of the few, Mei was considered an outlier in the transgender community and shunned as a “party pooper.”

However, Mei did not want to detransition, as she still detested being a man or living the gender role of a man. Interestingly, when asked if, when given a second chance, she would choose an alternative path, Mei said she would regret it if she did not undergo the surgery. She said if it were not for the surgery and her persistence to receive GAS, she would not be alive today, hinting at there being more to her GD and regret. Mei’s conflicted childhood of being adopted by a father that neglected and verbally abused her, the pressure and ingrained responsibilities of being the only grandson, and later on the betrayal in her first relationship due to her sex led Mei to detest her birth gender. She associated her life miseries with being a boy and this association continued on even after the surgery. These events caused her depression and anxiety, with the most evident stress seen during puberty, aligning with observation by Mirabella et al. (2020). It has been suggested that emotional distress and dysfunction can stem from the social context an individual lives in or stigmatization and violence, rather than from aspects of GD (Khoury et al., 2021; Robles et al., 2022). Emotional capriciousness and suicidal thoughts were what eventually pushed Mei to undergo GAS as her last resort. Furthermore, while Mei’s grandmother being part of her upbringing, provided her comfort in a relatively foreign adoptive family, at the same time, Mei felt a painful inner conflict of wanting to be herself and not wanting to displease her grandmother. Mei wasn’t even able to confide her truth to her closest family member. Insecure attachment patterns along with relationship adversity are potential concurrent risk factors to GD development that may interfere with free gender identity exploration (Giovanardi et al., 2018). Thus, when Mei’s narrative matched the DSM-5 diagnostic criteria for GD, questions should have been asked: was Mei truly a candidate for GAS? Or was GAS a way for her to evade her cultural/familial pain or the responsibilities she associated with being a boy (Withers, 2020)?

The causative mechanism underlying GD is complex and still poorly understood (Boucher & Chinnah, 2020). Higher prevalence of associated psychological comorbidities in the transgender community, such as depression, suicidal ideation, anxiety, body dysmorphia, and dissociative disorder, highlight the importance of psychological evaluations before GAS (María et al., 2021). First, helping patients to address external factors that interfere with gender identity development could provide them with more clarity regarding their dysphoria and management choices. In Mei’s case, first addressing her traumatic experiences and poor relationship with her father may have helped her become more comfortable with her body, thereby potentially avoiding the need for GAS. Preceding the decision to undergo GAS should be a diagnostic formulation that takes into account developmental, psychological, familial, social, and cultural factors (de Vries et al., 2011). Following GAS, the need to adapt to a new body or role and deal with new challenges or psychological stressors as a transgender person needs to be recognized, and the importance of additional psychotherapy should be emphasized (Dhejne et al., 2011). Moreover, as sexual satisfaction is influenced by many factors, in Mei’s case negative factors such as not having a partner, lacking physical sensation, and depression (De Cuypere et al., 2005; Holmberg et al., 2019), post-surgical sexual counseling is recommended to familiarize transwomen with their new genitalia and help them adapt to them.

In Taiwan, at the moment, there are no uniform diagnostic processes or post-surgical psychotherapy guidelines. While some psychiatrists conduct detailed and multidisciplinary evaluations over long periods of time, some prefer group therapy sessions. Mei only underwent some interviews regarding her GD and other psychological issues, as none of her psychiatrists specialized in transgender health. Moreover, if patients have access to specialty doctors without needing a general practitioner’s referral, they can choose their own psychiatrist. The diagnostic process differs greatly among psychiatrists regarding, for example, the time until certificate issuance, the cost of medical bills, the waiting list length, the involvement of other specialists, the required involvement of the patient’s parents, the type of therapy offered, and whether “experience as woman” was required.Footnote 3 Most transgender individuals tend to approach psychiatrists, regardless of whether they have experience with or a specialized in transgender medicine, who issue medical certificates within shorter periods of time as well as those who charge less and are closer to their home.

Another issue that calls for attention is the use of hormones. Mei did not start using feminizing hormones until 8 months before her surgery. While the World Professional Association for Transgender Health recommends 12 continuous months of reversible hormone use, some research has suggested that cumulative daily low-dose hormone therapy can decrease body-related uneasiness without the need of surgery, especially in transwomen who underwent feminizing GAS (Colizzi et al., 2015; Fisher et al., 2014). Mei might have benefited more from feminizing hormones if she had had continuous access to them at an earlier time. In addition, she was hesitant to use hormones initially due to her role as the only son in the family and her need to preserve sperms. Further research on the precise correlation between hormone use duration and GD, while in different cultural settings, is needed.

Due to her expectations of GAS solving dysphoria and dysphoria-related life problems, Mei was devastated when she realized that even the surgery could not make her feel like a woman, neither physically nor mentally. This emphasizes the significance of information transparency and, therefore, fully informed consent. It is highly recommended that, during the assessment phase, health professionals provide realistic expectations regarding aesthetic results, functional outcomes, and especially sexual performance, while ensuring that patients understand the limitations of the surgery, since GAS “damages” healthy organs irreversibly (De Cuypere & Vercruysse, 2009). Though GAS generally improves sexual satisfaction, every patient’s experience is unique, and betraying the patient’s expectations proved to be detrimental in Mei’s case. In addition, health professionals should ensure that patients understand the limitations of GAS when it comes to existing psychological issues before transition. Instead of having psychiatrists act as the sole controller of a GD diagnosis, the recruitment of a multidisciplinary team is essential from early on (White Hughto et al., 2015). Besides, maintaining a good balance between the patients’ fully informed consent and the health professionals’ diagnostic dominance preserves the patients’ authority over their experience, which may prevent dissatisfaction with the transition treatments (Schulz, 2018).

Variations in non-validated questionnaires and patient selection make it difficult to truly know how and how much patients are suffering from the consequences of regret. Most post-operative psychological outcomes are approximated at one point in time with general concepts such as QoL. Rarely are outcomes evaluated through elaborate narratives or long-term follow ups. Limitations in patient selection, such as defining regret only in those who have taken to reversal interventions (Littman, 2021; Wiepjes et al., 2018) or in those who have returned to their surgeon for a follow-up (Narayan et al., 2021), suggest an underestimation of regret after GAS. Moreover, in many Asian cultures, people are taught to maintain societal harmony and not speak out. The “shame socialization” upbringing where people are taught to focus on other’s affective responses to their behavior and to protect the family’s “face” and “honor” makes it even more difficult for individuals to come forward with their “mistake” of undergoing GAS (Lau et al., 2009). In addition, longer durations of post-GAS follow-up are necessary to determine the continuing benefits of surgery, as reports have shown a decrease in QoL after the first year (Passos et al., 2020). Finally, more large-scale qualitative research on regret based on a unitary method should be conducted over longer, well-defined follow-up periods, especially in individuals of diverse cultural upbringings (De Cuypere & Vercruysse, 2009).

Conclusion

Nobody anticipated Mei’s regret, not even herself. She approached her surgeon like every other transgender patient would: with two respective psychiatrist diagnoses that qualified her for drug therapy or surgery. It can be a challenge for psychiatrists to identify those with surgical needs and for surgeons to guarantee the effective alleviation of GD through GAS. Regret after GAS is often multifaceted and involves many underlying factors that may not stem from GD itself but from the patient’s family functioning and culture. The complexity of regret after GAS makes it difficult to predict it and emphasizes the need for more elaborate, large-scale qualitative research. Surgery and continued hormone treatment constitute only part of the gender transition. Continuous psychological counseling and social and family support are equally, if not more, important for helping transgender people successfully adjust to their new gender identity.