On women, we found a positive effect of hormonal contraceptives on frequency of vaginal intercourse and a negative effect of hormonal contraceptives on masturbation frequency

Hormonal Contraception and Sexuality: Causal Effects, Unobserved Selection, or Reverse Causality?Laura J. Botzet, Tanja M. Gerlach, Julie C. Driebe, Lars Penke, Ruben C. Arslan. Collabra: Psychology (2021) 7 (1): 29039. Oct 21 2021. https://doi.org/10.1525/collabra.29039

Many of the women who take hormonal contraceptives discontinue because of unwanted side effects, including negative psychological effects. Yet scientific evidence of psychological effects is mixed, partly because causal claims are often based on correlational data. In correlational studies, possible causal effects can be difficult to separate from selection effects, attrition effects, and reverse causality. Contraceptive use and, according to the congruency hypothesis, congruent contraceptive use (whether a woman’s current use/non-use of a hormonal contraceptive is congruent with her use/non-use at the time of meeting her partner) have both been thought to influence relationship quality and sexual functioning. In order to address potential issues of observed and unobserved selection effects in correlational data, we studied a sample of up to 1,179 women to investigate potential effects of contraceptive use and congruent contraceptive use on several measures of relationship quality and sexual functioning: perceived partner attractiveness, relationship satisfaction, sexual satisfaction, and diary measurements including libido, frequency of vaginal intercourse, and frequency of masturbation. No evidence for substantial effects was found except for a positive effect of hormonal contraceptives on frequency of vaginal intercourse and a negative effect of hormonal contraceptives on frequency of masturbation. These effects were robust to the inclusion of observed confounders, and their sensitivity to unobserved confounders was estimated. No support for the congruency hypothesis was found. Our correlational study was able to disentangle, to some extent, causal effects of hormonal contraceptives from selection effects by estimating the sensitivity of reported effects. To reconcile experimental and observational evidence on hormonal contraceptives, future research should scrutinize the role of unobserved selection effects, attrition effects, and reverse causality.

Keywords: sexual frequency, sexuality, relationship quality, sex hormones, contraception

Discussion

Our study aimed to disentangle selection effects from causal effects of contraceptive use. It showed that additional selection effects (including information about demography and personality) did not describe the choice of contraceptive method and congruent contraceptive use substantially better than did selection effects of age, income, and relationship duration. Furthermore, there was no evidence for substantial effects of contraceptive method, congruent contraceptive use, and their interaction on perceived partner attractiveness, relationship satisfaction, sexual satisfaction, and libido. While congruent contraceptive use and its interaction with contraceptive use had no substantial effects on frequency of vaginal intercourse and frequency of masturbation, we found a positive effect of current use of hormonal contraceptives on frequency of vaginal intercourse and a negative effect of current use of hormonal contraceptives on frequency of masturbation. These links were robust to the inclusion of observed confounders and sensitivity analyses suggested that unobserved confounders would need to strongly influence outcomes (about as strong as all observed confounders taken together) in order to substantially alter conclusions.

Selection Effects

Including additional selection variables pertaining to demography (education) and personality (openness, conscientiousness, extraversion, agreeableness, neuroticism, and religiosity) did not substantially improve models predicting contraceptive method or congruent contraceptive use compared to models based only on age, relationship duration, and income. Therefore, Hypothesis 1—that the complex model explains more variance compared to the simple model in (1) the choice of contraception and (2) congruent contraceptive use—was rejected.

Of the predictors included in the simpler models, age and relationship duration had a significant effect on choice of contraceptive method and congruent contraceptive use; income was no significant predictor. Overall, age had a negative effect on the use of hormonal contraceptives, i.e. the percentage of women using hormonal contraceptives decreased with increasing age. In addition, age had a negative effect on congruency in women who were using hormonal contraceptives when they met their partner (i.e., older women were more likely to switch to no/nonhormonal contraceptives) but a positive effect on congruency in women who were using no/nonhormonal contraceptives when they met their partner (i.e., younger women were more likely to switch to hormonal contraceptives). Overall, women in a romantic relationship were more likely to use hormonal contraceptives. Relationship length played no significant role in choice of contraceptive use, but partnered women who were in longer relationships were more likely to switch contraceptive methods, independent of whether they had been using hormonal contraceptives or no/nonhormonal contraceptives when they met their partner. Even though the complex models showed no improvement in model fit over the simple models, three predictors in the complex models stood out: First, conscientiousness had a positive effect on hormonal contraceptive use and a positive effect on congruent contraceptive use in women who had been using hormonal contraceptives when they met their partner (i.e., they were more likely to continue using hormonal contraceptives). Second, openness had a negative effect on hormonal contraceptive use and a negative effect on congruent contraceptive use in women who had been using hormonal contraceptives when they met their partner (i.e., they were more likely to switch to no/nonhormonal contraceptives). Third, agreeableness had a positive effect on congruent contraceptive use in women who had been using hormonal contraceptives when they met their partner (i.e., they were more likely to continue using hormonal contraceptives) and a negative effect on congruent contraceptive use in women who had been using no/nonhormonal contraceptives when they met their partner (i.e., they were more likely to switch to hormonal contraceptives). Future research concerning selection effects on contraceptive use and congruent contraceptive use could consider excluding measures of income (where appropriate⁶) and including measures of conscientiousness, openness, and agreeableness in addition to age and relationship duration.

Table 3. Unstandardized Effect Size Estimates of Hormonal Contraceptives on Outcomes

Effects of Hormonal Contraceptives

The evidence for effects of hormonal contraceptives is inconclusive on perceived partner attractiveness, relationship satisfaction, sexual satisfaction, and libido, therefore neither accepting nor rejecting Hypothesis 2.1(1–4)—hormonal contraceptives lead to decreased (1) perceived partner attractiveness, (2) relationship satisfaction, (3) sexual satisfaction, and (4) libido—and Hypothesis 2.2(1–4)—after controlling for all selection variables, hormonal contraceptives lead to decreased (1) perceived partner attractiveness, (2) relationship satisfaction, (3) sexual satisfaction, and (4) libido. The estimates were insufficiently precise; future research with even larger samples is needed to reach a conclusion. Nevertheless, given the rather small effect sizes, it appears unlikely that use of hormonal contraceptives has a strong association with these outcomes.

Hormonal contraceptives had a positive effect on frequency of vaginal intercourse, even after controlling for observed confounders—thereby rejecting Hypotheses 2.1(5) and 2.2(5). Contrary to the RCTs by Graham et al. (1995) and Zethraeus et al. (2016) that provided evidence for negative effects of hormonal contraceptives on sexual desire, sexual arousal, and sexual pleasure, the results of our study are in line with studies based on correlational data that found a positive relationship between hormonal contraceptives and sexual frequency (Alexander et al., 1990; Caruso et al., 2005; McCoy & Matyas, 1996).

Hormonal contraceptives had a negative effect on frequency of masturbation, even after controlling for observed confounders—thereby accepting Hypotheses 2.1(6) and 2.2(6). Most studies show no difference in frequency of masturbation between HC users and non-HC users (Alexander et al., 1990; Bancroft et al., 1991), but a recent study by Mark et al. (2016) provided evidence of a positive association between hormonal contraceptives and women’s dyadic libido and a negative association between hormonal contraceptives and women’s solitary libido. The libido item in our study included dyadic and solitary libido (“I experienced increased libido [desire to have sexual intercourse/to masturbate/to be sexually active].”) and did not distinguish between them as proposed by Spector et al. (1996). Thus, it seems possible that the divergent relationships described by Mark et al. (2016) resulted in the overall null relationship between hormonal contraceptives and libido that we observed. Our study could therefore provide evidence for behavioral consequences (measured as frequency of vaginal intercourse and frequency of masturbation) of the divergent relationships between hormonal contraceptives and dyadic and solitary libido described by Mark et al. (2016).

Effects of Congruent Contraceptive Use

Evidence was inconclusive on effects of congruent contraceptive use on perceived partner attractiveness, relationship satisfaction, sexual satisfaction, libido, frequency of vaginal intercourse, and frequency of masturbation after considering observed confounders. We could therefore neither accept nor reject Hypotheses 3.1—congruent contraceptive use leads to increased (1) perceived partner attractiveness, (2) relationship satisfaction, (3) sexual satisfaction, (4) libido, (5) frequency of vaginal intercourse, and (6) frequency of masturbation—and 3.2—after controlling for all selection variables, congruent contraceptive use leads to increased (1) perceived partner attractiveness, (2) relationship satisfaction, (3) sexual satisfaction, (4) libido, (5) frequency of vaginal intercourse, and (6) frequency of masturbation.

While these findings do not support most of the literature based on the congruency hypothesis (Birnbaum et al., 2019; Cobey et al., 2013; French & Meltzer, 2020; Roberts, Cobey, et al., 2014; Roberts et al., 2012; Roberts, Little, et al., 2014; Russell et al., 2014), they are in line with a recent large-scale replication attempt by Jern et al. (2018). Marcinkowska et al. (2019) provided additional evidence that questions the congruency hypothesis: In a large-scale study (n = 6,482), they found no evidence that women using the pill had weaker preferences for male facial masculinity than did women not using the pill. Differences in partner preferences have been suggested to be the driving mechanism behind the congruency hypothesis: Incongruent contraceptive methods are thought to lead to a shift in partner preferences, resulting in less satisfaction with the current romantic partner.

Jern et al. (2018) pointed out an important difference between their study and earlier studies on the congruency hypothesis: Earlier studies often had unequal distributions of congruent and incongruent users such that one group was almost entirely based on HC users or non-HC users. For instance, in the study by Cobey et al. (2013) the group of incongruent current HC users consisted of only four participants (3% of the final sample), while the group of congruent HC users consisted of 71 participants (59% of the final sample). This is especially problematic because most studies featured relatively small incongruent HC user groups and relatively large congruent HC user groups. Considering the small expected effect sizes based on the congruency hypothesis, main effects of current contraceptive use could have led to a spurious effect of congruency based on unequal distributions. Although the sample sizes of congruent and incongruent use differed in our study, the subgroups were relatively balanced (congruent non-HC users: 32%; congruent HC users: 31%; incongruent non-HC users: 19%; incongruent HC users: 17%) and the models always accounted for current contraceptive use and its interaction with contraceptive congruency.

Table 4. Unstandardized Effect Size Estimates of Hormonal Contraceptives, Congruent Contraceptive Use, and Their Interaction on Outcomes

Another possibility is that the reported effects based on the congruency hypothesis were false positives (Simmons et al., 2011). None of the earlier studies used preregistered hypotheses, and sample sizes were relatively small (ranging between n = 48 and n = 365), apart from the study by Roberts et al. (2012), which found a positive effect of congruent use on perceived partner attractiveness and sexual satisfaction (n = 993). Indeed, two failed large-scale replication attempts (Jern et al., 2018 and the current study) and a range of recent evidence question the theory underlying the congruency hypothesis (Arslan et al., 2018; C. R. Harris et al., 2013; Jones, Hahn, & DeBruine, 2018; Jünger, Kordsmeyer, et al., 2018; Jünger, Motta-Mena, et al., 2018; Stern et al., 2020; Stern & Penke, in press; Wood et al., 2014; for a current discussion on evidence for psychological cycle shifts see Gangestad et al., 2019a, 2019b; Higham, 2019; Jones, Hahn, & DeBruine, 2018; Roney, 2019; Stern et al., 2019).

Overall, recent work has cast doubt on the evidence for both the assumed mechanism and the interaction effect underlying the congruency hypothesis. Our study could not accept the null hypotheses that there are no effects of congruent contraceptive use on perceived partner attractiveness, relationship satisfaction, sexual satisfaction, libido, frequency of vaginal intercourse, and frequency of masturbation because the sample size was too small and because we applied rigorous decision criteria for accepting the null hypotheses. Future research on congruent contraceptive use should be preregistered, be adequately powered to detect small effects, and appropriately account for current and past contraceptive use.

Sensitivity to Unobserved Confounders

We estimated the robustness of the effects of hormonal contraceptives and congruent contraceptive use in light of potential unobserved confounders. Sensitivity analysis suggested that the influence of unobserved confounders would need to be nearly 1.5 times as strong as the influence of observed confounders to fully account for the effect of hormonal contraceptives on frequency of vaginal intercourse, and nearly as strong as the influence of observed confounders to fully account for the effect of hormonal contraceptives on frequency of masturbation. Even when taking into account the broad range of included observed confounders (demography, personality, and romantic relationship information) it seems plausible that unobserved confounders might exist that would fully explain the reported effects of hormonal contraceptives on frequency of vaginal intercourse and frequency of masturbation. Besides potential unobserved selection effects, we now consider three additional possible challenges: reverse causality, attrition effects, and further unobserved confounders.

Selection Effects and Reverse Causality

There was a positive effect of hormonal contraceptive use on frequency of vaginal intercourse. Although frequency of vaginal intercourse was measured after contraception in the diary, it is somewhat habitual and thus stable. Reverse causality might therefore be at play, even after excluding women who were not sexually active and therefore not using hormonal contraception. Women who have sex more frequently might place a larger premium on safeness and convenience for contraception. Higher frequency of vaginal intercourse is associated with a higher risk of (unwanted) pregnancy, and therefore safe contraception is even more important, especially if a woman does not want to forego sexual intercourse or use additional contraceptive methods. In addition, higher frequency of vaginal intercourse affects economic considerations: At higher sexual frequencies, the pill can be cheaper than condoms. Reverse causation would explain why there are effects on behavior (frequency of vaginal intercourse) but not on the psychological outcomes that might be expected to precede the behavior in the causal chain (libido and sexual satisfaction). A similar, if slightly more speculative, explanation could be plausible for frequency of masturbation. If women who have sexual intercourse only infrequently eschew the pill and its cost and side effects, they might instead opt to use condoms. If these women have the same level of libido as women who have sex more frequently, they might masturbate more. Because the stable component of some of these outcomes could be quite large, these are plausible unobserved confounders, and repeated longitudinal data would be needed to adjust for them.

Attrition Effects

Unlike our study, RCTs reported negative effects of hormonal contraceptives on libido, sexual arousal, and sexual pleasure (Graham et al., 1995; Zethraeus et al., 2016) as well as on general well-being (Zethraeus et al., 2017). One potential reason for the positive effect of hormonal contraceptives on frequency of vaginal intercourse reported in our study and in earlier correlational studies (Alexander et al., 1990; Caruso et al., 2005; McCoy & Matyas, 1996) are attrition effects. As Graham (2019) noted, there is great variability in women’s experiences with hormonal contraceptives, with reports of negative, positive, and no effects. Women with negative experiences were more likely to stop using hormonal contraceptives (Bancroft & Sartorius, 1990; Sanders et al., 2001), and discontinuation rates are high. For instance, 11.6% of Swedish women who took hormonal contraceptives for the first time stopped using them within six months (Josefsson et al., 2013). Predictors of discontinuation include emotional side effects, worsening of the premenstrual syndrome, decreased frequency of sexual thoughts, and decreased psychosexual arousability (Sanders et al., 2001). Women with depressive and premenstrual complaints tend to discontinue hormonal contraceptive use, leaving the remaining users with greater reported well-being (Bancroft & Sartorius, 1990). Therefore, it is likely that empirical, correlative evidence suggesting positive effects of hormonal contraceptives on sexual functioning stems at least in part from the fact that women with negative experiences of hormonal contraceptives switch to other contraceptive methods. Much of the current evidence on positive effects of hormonal contraceptives might thus rest on samples skewed toward women who have already tailored their contraception regimen to their experiences with hormonal contraceptives; reported correlations could even be the reverse of the average causal effect. This may also be the case in our study: The estimated effect of hormonal contraceptives may not equal their average effect because women with negative experiences of hormonal contraceptives had already stopped taking them. Women who continued using hormonal contraceptives would be more likely to have had positive experiences with them, which would result in an overall positive relationship between hormonal contraceptive use and frequency of vaginal intercourse based on correlational data masking negative causal effects on average. Analyses on the congruency of contraceptive use at the time of meeting the current partner can only partly address this, as participants were generally old enough to have been able to try out different methods of contraception before meeting their current partner. This limitation implies that estimated effects should not be expected to generalize to the experiences of women using hormonal contraceptives for the first time. Attrition effects could be studied using longitudinal data. In addition, research on women using hormonal contraceptives for the first time could provide more information on how preferences for contraceptives form.

Further Unobserved Confounders

Besides the already included selection and outcome variables, frequency of vaginal intercourse has been found to relate to less restricted sociosexuality (Grøntvedt et al., 2020), increased satisfaction with own body image (Ackard et al., 2000), and increased satisfaction with life (Muise et al., 2016) in women. Frequency of masturbation has been found to be positively associated with less restricted sociosexuality (Velten & Margraf, 2017), body acceptance and orgasm frequency (Burri & Carvalheira, 2019), and greater importance of sex and higher levels of general anxiety and depression (Rowland et al., 2020) in women. Regnerus et al. (2017) reported a negative relationship between frequency of masturbation and contentment with sexual frequency.

While some of these potential unobserved confounders were not measured in the available dataset (in particular orgasm frequency, importance of sex, anxiety, depression, and contentment with sexual frequency), others would have been available (in particular sociosexuality, general life satisfaction, and satisfaction with own body image) but we decided not to include them in the current study to prevent controlling for potential colliders or mediators (Rohrer, 2018). Nevertheless, they could be strong unobserved confounders that could explain the observed links between hormonal contraceptive use and frequency of vaginal intercourse and frequency of masturbation. For example, higher desire for penetrative intercourse could lead to higher frequency of vaginal intercourse. At the same time, it could lead to the decision to use hormonal contraceptives because they are among the safest contraceptive methods available. Body acceptance could lead to higher frequency of masturbation and, at the same time, to the decision to use no/nonhormonal contraceptives in order to avoid artificial hormones. Therefore, even though our study quantitatively estimated the needed strength of unobserved confounders, it is unable to definitively rule out the possibility that the observed relationships are due to the influence of potential unobserved confounders. In future research on larger samples, more pointed comparisons of contraceptives with similar Pearl indices indicating the effectiveness of this birth control (e.g., the pill and intrauterine devices) might answer some of these questions, and again, examining within-subject changes in sexuality in longitudinal data would reduce some of the concerns about potential unobserved confounders.

Causal Effects of Hormonal Contraceptives on Frequency of Vaginal Intercourse and Frequency of Masturbation?

Our study provides evidence for a positive effect of hormonal contraceptives on frequency of vaginal intercourse and a negative effect of hormonal contraceptives on frequency of masturbation. Both effects were somewhat attenuated when adjusting for observed confounders. Fairly strong unobserved confounders would be necessary to nullify or reverse the remaining effects but some plausible candidates exist. The questions of reverse causality, selection effects, and attrition effects regarding the reported effects persist.

Limitations and Strengths

Our study was not without limitations: First, while the total sample size of our study was relatively large, the sample sizes used for the analyses—especially those investigating effects of congruent contraceptive use—were too small to reach a definite conclusion about potential effects. Second, even though our study provides valuable insights into the links between contraceptive use, relationship quality, and sexual functioning, the conclusions based on correlational data remain inconclusive about any putative causal effect of hormonal contraceptives.

Nevertheless, our study had several key strengths: First, even though conclusions remain cautious because of the available sample size, the size of the sample still exceeds domain standards. Second, measures for libido, frequency of vaginal intercourse, and frequency of masturbation were based on diary reports, which have been shown to be more reliable than retrospective behavior measurements (McAuliffe et al., 2007) and described as the gold standard for measuring sexual frequency by Graham et al. (2003). Third, by providing a directed acyclic graph, controlling for observed confounding, and estimating the sensitivity to unobserved confounding, this study is better positioned than previous correlational work to disentangle selection effects from causal effects.

Constraints on Generality

Following the guidelines on constraints on generality (Simons et al., 2017) the following four factors reduce the broad generalizability of the current results: First, the sample studied consisted of heterosexual WEIRD (Henrich et al., 2010) women with a high proportion of undergraduate psychology students. Although our main explanation assumes a universal biological mechanism for the results, different absolute hormone levels in less prosperous and well-nourished populations (Vitzthum, 2009) might affect the frequency of ovulation and hence the observable effect size. Moreover, some of our alternative explanations (such as reverse causality) may be much more dependent on circumstances. Second, even though the gold standard for measuring sexual frequency and masturbation frequency by using diary reports was applied, all results are purely based on self-reports and generalizability to other measures might be limited. Third, from a temporal perspective the composition of hormonal contraceptives (e.g., the dosage of estrogen and progestin) has changed over the decades and will change further in the future. If the reported effects are due to certain estrogen or progestin dosages, results might not be replicable based on samples from different times.

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Frequent I-talk is also positively related to the neurotic variety of narcissism (vulnerable narcissism); also has a positive association with sociodemographic characteristics such as (lower) status, (younger) age, & (female) gender

The story of “I” tracking: Psychological implications of self-referential language use. Amunet K. Berry-Blunt, Nicholas S. Holtzman, M. Brent Donnellan, Matthias R. Mehl. Social and Personality Psychology Compass, October 19 2021. https://doi.org/10.1111/spc3.12647

Abstract: We review extant research on the psychological implications of the use of first-person singular pronouns (i.e., “I-talk”). A common intuition is that I-talk is associated with an overly positive, highly agentic, and inflated view of the self—including arrogance, self-centeredness, and grandiose narcissism. Initial (small-sample) research provided evidence that frequent I-talk was associated with grandiose narcissism. More recent (large-sample) research, however, has found that the correlation is near zero. Frequent I-talk is, however, positively correlated with depressive symptoms, in particular, and negative emotionality (i.e., neuroticism), more broadly. Frequent I-talk is also positively related to the neurotic variety of narcissism called vulnerable narcissism. In addition, frequent I-talk has a positive association with sociodemographic characteristics such as (lower) status, (younger) age, and (female) gender; I-talk has a conditional association with truth-telling and authenticity—a correlation that appears to hinge on context. This review summarizes the literature on I-talk, provides some speculations about the emergent psychological meanings of I-talk, and provides a guide for future research.

Greater survivability of cardio vascular events allows lifestyle choices to catch-up with people

Dahl, Gordon B. and Kreiner, Claus Thustrup and Nielsen, Torben and Serena, Benjamin Ly, Understanding the Rise in Life Expectancy Inequality. IZA Discussion Paper No. 14741, Oct 8 2021, SSRN: https://ssrn.com/abstract=3934758

Abstract: We provide a novel decomposition of changing gaps in life expectancy between rich and poor into differential changes in age-specific mortality rates and differences in "survivability". Declining age-specific mortality rates increases life expectancy, but the gain is small if the likelihood of living to this age is small (ex ante survivability) or if the expected remaining lifetime is short (ex post survivability). Lower survivability of the poor explains between one-third and one-half of the recent rise in life expectancy inequality in the US and the entire change in Denmark. Our analysis shows that the recent widening of mortality rates between rich and poor due to lifestyle-related diseases does not explain much of the rise in life expectancy inequality. Rather, the dramatic 50% reduction in cardiovascular deaths, which benefited both rich and poor, made initial differences in lifestyle-related mortality more consequential via survivability.

Keywords: mortality, life expectancy, inequality

JEL Classification: I14, J10

The devil is in the detail: reflections on the value and application of cognitive interviewing to strengthen quantitative surveys in global health

The devil is in the detail: reflections on the value and application of cognitive interviewing to strengthen quantitative surveys in global health. K Scott, O Ummer, A E LeFevre. Health Policy and Planning, Volume 36, Issue 6, July 2021, Pages 982–995, https://doi.org/10.1093/heapol/czab048

Abstract: Cognitive interviewing is a qualitative research method for improving the validity of quantitative surveys, which has been underused by academic researchers and monitoring and evaluation teams in global health. Draft survey questions are administered to participants drawn from the same population as the respondent group for the survey itself. The interviewer facilitates a detailed discussion with the participant to assess how the participant interpreted each question and how they formulated their response. Draft survey questions are revised and undergo additional rounds of cognitive interviewing until they achieve high comprehension and cognitive match between the research team’s intent and the target population’s interpretation. This methodology is particularly important in global health when surveys involve translation or are developed by researchers who differ from the population being surveyed in terms of socio-demographic characteristics, worldview, or other aspects of identity. Without cognitive interviewing, surveys risk measurement error by including questions that respondents find incomprehensible, that respondents are unable to accurately answer, or that respondents interpret in unintended ways. This methodological musing seeks to encourage a wider uptake of cognitive interviewing in global public health research, provide practical guidance on its application, and prompt discussion on its value and practice. To this end, we define cognitive interviewing, discuss how cognitive interviewing compares to other forms of survey tool development and validation, and present practical steps for its application. These steps cover defining the scope of cognitive interviews, selecting and training researchers to conduct cognitive interviews, sampling participants, collecting data, debriefing, analysing the emerging findings, and ultimately generating revised, validated survey questions. We close by presenting recommendations to ensure quality in cognitive interviewing.

Keywords: Cognitive interviewing, survey research, validity, methodological innovation, qualitative research

Introduction

This methodological musing calls attention to cognitive interviewing, a qualitative research methodology for improving the validity of quantitative surveys that has often been overlooked in global public health. Cognitive interviewing is ‘the administration of draft survey questions while collecting additional verbal information about the survey responses, which is used to evaluate the quality of the response or to help determine whether the question is generating the information that its author intends’ (Beatty and Willis, 2007). This methodology helps researchers see survey questions from the participants’ perspectives rather than their own by exploring how people process information, interpret the words used and access the memories or knowledge required to formulate responses (Drennan, 2003).

Cognitive interviewing methodology emerged in the 1980s out of cognitive psychology and survey research design, gaining prominence in the early 2000s (Beatty and Willis, 2007). Cognitive interviewing is widely employed by government agencies in the preparation of public health surveys in many high-income countries [e.g. the Collaborating Center for Questionnaire Design and Evaluation Research in the Center for Disease Control and Prevention (CDC)/National Center for Health Statistics (2014) and Agency for Healthcare Research and Quality in the Department of Health and Human Services (2019) in the USA and the Quality Care Commission (2019) for the National Health Service Patient Surveys in the UK]. Applications in the global public health space are emerging, including to validate measurement tools undergoing primary development in English and for use in English [e.g. to measure family response to childhood chronic illness (Knafl et al., 2007)]; to support translation of scales between languages [e.g. to validate the London Measure of Unplanned Pregnancy for use in the Chichewa language in Malawi (Hall et al., 2013)] and to assess consumers’ understanding and interpretation of and preferences for displaying information [e.g. for healthcare report cards in rural Tajikistan (Bauhoff et al., 2017)]. However, this methodology remains on the periphery of survey tool development by university-based academic researchers and monitoring and evaluation teams working in global health; most surveys are developed, translated and adapted without cognitive interviews, and publications of survey findings rarely stipulate that cognitive interviews took place as part of tool development processes.

Box 1.

The need for cognitive interviewing: examples from developing a tool to measure respectful maternity care among rural women in central India

Context: respectful maternity care in rural central India

We used cognitive interviewing to examine survey questions for rural central India, adapted from validated instruments to measure respectful maternity care used in Ethiopia, Kenya and elsewhere in India. This process illuminated extensive cognitive mismatch between the intent of the original questions and how women interpreted them, which would have compromised the validity of the survey’s findings (Scott et al., 2019). Two examples are provided here.

Cognitive interviews revealed that hypothetical questions were interpreted in unexpected ways

A question asked women whether they would return to the same facility for a hypothetical future delivery. The researchers intended the question to assess satisfaction with services. Some women replied no, and, upon probing, explained that their treatment at the facility was fine but that they had no intention of having another child. Other women said yes, despite experiencing some problematic treatment, and probing revealed that they said this because they were too poor to afford to go anywhere else.

Cognitive interviews revealed that Likert scales were inappropriate

The concept of graduated agreement or disagreement with a statement was unfamiliar and illogical to respondents. Women did not understand how to engage with the Likert scales we tested (5-, 6- and 10-point scales, using numbers, words, colours, stars, and smiley faces). Most respondents avoided engaging with the Likert scales, instead responding in terms of a dichotomous yes/no, agree/disagree, happened/did not happen, etc., despite interviewer’s attempts to invite respondents to convert their reply to a Likert response. For example, when asked to respond on a 6-point Likert scale to the statement ‘medical procedures were explained to me before they were conducted’, a respondent only repeated ‘they didn’t explain’. Other respondents, when shown a smiley face Likert scale, focused on identifying a face that matched how they felt rather than that depicted their response to the statement in question. For example, when asked to respond to the statement ‘the doctors and nurses did everything they could to help me manage my pain’, a respondent pointed to a sad face, explaining that although the doctors and nurses helped her, since she was in pain her face was ‘like this’ (i.e. sad). Without cognitive interviews, survey enumerators would unknowingly record responses unrelated to the question at hand or would attempt to fit respondent dichotomous answers into Likert scales using whatever interpretation the enumerator saw fit.

Cognitive interviewing recognizes that problems with even one detail of a survey question can compromise the validity of the data gathered, whether it is an improper word, confusing phrasing, unfamiliar concept, inappropriate response option, or other issue. Without cognitive interviews, gaps between question intent and respondent interpretation can persist, severely compromising the quality of data generated from surveys (Box 1). Furthermore, cognitive mismatch is often impossible to detect after data collection. Instead, responses recorded in the survey are taken as ‘true’, regardless of whether the respondents understood and answered the question in the intended manner and regardless of the assistance, adjustment, or interpretation provided by enumerators.

In this article, we argue that cognitive interviewing should be an essential step in the development of quantitative survey tools used in global public health and call attention to the detailed steps of applying this method in the field. We start by reviewing what cognitive interviewing is and consider the varied definitions and use cases in survey tool development. We next outline the recommended steps in survey tool development and then provide an overview of how to go about cognitive interviewing. We close by reflecting on the broader implications of cognitive interviewing.

While people themselves were the most accurate about the majority of their abilities, their verbal and spatial intelligence were only estimable by informants or strangers, respectively

Hofer, Gabriela, Laura Langmann, Roman Burkart, and Aljoscha Neubauer. 2021. “Who Knows What We Are Good At? Unique Insights of the Self, Knowledgeable Informants, and Strangers into a Person’s Abilities.” PsyArXiv. October 21. doi:10.31234/osf.io/u73xf

Abstract: Who is the best judge of a person’s abilities—the person, a knowledgeable informant or strangers just met in a 3-min speed date? To test this, we collected ability measures as well as self-, informant- and stranger-estimates of verbal, numerical and spatial intelligence, creativity, and intra- and interpersonal emotional competence from 175 young adults. While people themselves were the most accurate about the majority of their abilities, their verbal and spatial intelligence were only estimable by informants or strangers, respectively. These differences in accuracy were not accompanied by differences in the domains’ relevance to people’s self-worth or observability to strangers. These results indicate self-other knowledge asymmetries for abilities but raise questions about the reasons behind these asymmetries.

Rolf Degen summarizing... We blindly impute higher moral qualities to good-looking people, even more so than qualities of a non-moral kind

Beauty Goes Down to the Core: Attractiveness Biases Moral Character Attributions. Christoph Klebl, Joshua J. Rhee, Katharine H. Greenaway, Yin Luo & Brock Bastian. Journal of Nonverbal Behavior, Oct 20 2021. https://link.springer.com/article/10.1007/s10919-021-00388-w

Abstract: Physical attractiveness is a heuristic that is often used as an indicator of desirable traits. In two studies (N = 1254), we tested whether facial attractiveness leads to a selective bias in attributing moral character—which is paramount in person perception—over non-moral traits. We argue that because people are motivated to assess socially important traits quickly, these may be the traits that are most strongly biased by physical attractiveness. In Study 1, we found that people attributed more moral traits to attractive than unattractive people, an effect that was stronger than the tendency to attribute positive non-moral traits to attractive (vs. unattractive) people. In Study 2, we conceptually replicated the findings while matching traits on perceived warmth. The findings suggest that the Beauty-is-Good stereotype particularly skews in favor of the attribution of moral traits. As such, physical attractiveness biases the perceptions of others even more fundamentally than previously understood.

The Mid-Life Dip in Well-Being: We find remarkably strong and consistent evidence across countries of statistically significant and non-trivial U-shapes in age with and without socio-economic controls

The Mid-Life Dip in Well-Being: a Critique. David G. Blanchflower & Carol L. Graham. Social Indicators Research, Oct 19 2021. https://link.springer.com/article/10.1007/s11205-021-02773-w

Abstract: A number of studies—including our own—find a mid-life dip in well-being. Yet several papers in the psychology literature claim that the evidence of a U-shape is "overblown" and if there is such a thing that any such decline is "trivial". Others have claimed that the evidence of a U-shape "is not as robust and generalizable as is often assumed," or simply "wrong." We identify 409 studies, mostly published in peer reviewed journals that find U-shapes that these researchers apparently were unaware of. We use data for Europe from the Eurobarometer Surveys (EB), 1980–2019; the Gallup World Poll (GWP), 2005–2019 and the UK's Annual Population Survey, 2016–2019 and the Census Bureau's Household Pulse Survey of August 2021, to examine U-shapes in age in well-being. We find remarkably strong and consistent evidence across countries of statistically significant and non-trivial U-shapes in age with and without socio-economic controls. We show that studies cited by psychologists claiming there are no U-shapes are in error; we reexamine their data and find differently. The effects of the mid-life dip we find are comparable to major life events such as losing a spouse or becoming unemployed. This decline is comparable to half of the unprecedented fall in well-being observed in the UK in 2020 and 2021, during the Covid19 pandemic and lockdown, which is hardly “inconsequential” as claimed.

Discussion

An early psychology literature argued that there was no relationship between well-being and age. This appears to have been based on studies that included a handful of people with tiny sample sizes. Even where there was evidence of a U-shape, it was denied in the literature. We reworked a few of these studies using same data and showed there were U-shapes, and their scale was large and comparable to the loss of a spouse, or a job. Some studies have failed to find U-shapes but generally they have been based on small sample sizes,

In addition to our findings of U-shapes using life satisfaction data from the Eurobarometer we also looked at Cantril's ladder of life satisfaction in the Gallup World Poll data and found U-shapes with and without controls for an additional 64 non-European countries. We found similar U-shapes for the UK from the Annual Population Surveys.

Two more recent papers (Galambos et al., 2020, 2021) suggested there was little evidence of U-shapes based on a literature review of 28 papers. We showed that that the authors had misclassified many of these paper's findings. Indeed, after misclassifications have been accounted for and ineligible studies dropped, B&G found that there were zero that didn't find any evidence of U-shapes. Of the 28 papers 21 found U-shapes and three had mixed evidence while four had to be excluded as they did not set the criteria set by GKJL1; of note is that GKJL2 did not dispute any of these re-classifications.

We have also identified an astonishing 387 additional papers that the authors had ignored that did find U-shapes, making 403 in total. Indeed, we count a total of 373 published in a vast array of peer-reviewed journals in English, including 73 in this journal alone, that find U-shapes, which was the main criterion the authors set for examination. When this was pointed out to the authors by us in an earlier paper (Blanchflower & Graham, 2021a) the authors claimed that they did not set out to do an exhaustive review because they "wanted to show support for the view that not all researchers find the U shapes". Hence, their analysis is advocacy not science. There is a U-shape in well-being in midlife.

On the basis of this evidence, it is clearly inappropriate to dismiss the literature on the U-curve as “overblown” or the scale of the effects as trifling, inconsequential or even "trivial". We have shown that the effects of the mid-life dip are comparable to major life events like losing a spouse or a job. We show that the drop from teenage years to the midlife low is about half the size of the unprecedented drop in life satisfaction that occurred during the COVID19 pandemic.

Beyond being empirically interesting, there are implications for substantial parts of the world’s population. These dips in well-being are associated with higher levels of depression, including chronic depression, difficulty sleeping, and even suicide. In the U.S., deaths of despair are most likely to occur in the middle-aged years, and the patterns are robustly associated with unhappiness and stress. Across countries chronic depression and suicide rates peak in midlife. The mid-life dip in well-being is robust to within person analysis, also exists with the prescribing of anti-depressants and it extends beyond humans. The evidence comes from both longitudinal and cross-section data, which complement one another, as noted in a recent report by The Lancet’s COVID-19 Commission Mental Health Task Force. It remains puzzling then why some psychologists continue to suggest that well-being is unrelated to age.

Based on the significant evidence we present, the decline in mid-life well-being seems real and consequential and has robust linkages to other serious markers of ill-being. The mid-life dip is real, it applies to most of the world’s population, excepting countries in which it is very difficult to age—such as those with very high levels of absolute poverty and conflict and low levels of life expectancy. It links to behaviors and outcomes that merit the attention of scholars and policymakers alike. These include rising rates of despair and reported pain among the middle-aged in many rich countries and associated premature mortality due to despair-related deaths, and some similar if less well documented patterns in developing economies. Among other things, more public awareness of how common this mid-life dip is might help those navigating its worst manifestations to make it through to a happier and longer life.

The overwhelming evidence from four hundred and nine papers, and counting, as well as the evidence presented here, support the conclusion that there is a midlife low in well-being. This is among the most striking, persistent and consistent patterns in social science. 

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Lisa Littman. Archives of Sexual Behavior, Oct 19 2021. https://link.springer.com/article/10.1007/s10508-021-02163-w

Abstract: The study’s purpose was to describe a population of individuals who experienced gender dysphoria, chose to undergo medical and/or surgical transition and then detransitioned by discontinuing medications, having surgery to reverse the effects of transition, or both. Recruitment information with a link to an anonymous survey was shared on social media, professional listservs, and via snowball sampling. Sixty-nine percent of the 100 participants were natal female and 31.0% were natal male. Reasons for detransitioning were varied and included: experiencing discrimination (23.0%); becoming more comfortable identifying as their natal sex (60.0%); having concerns about potential medical complications from transitioning (49.0%); and coming to the view that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38.0%). Homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was expressed by 23.0% as a reason for transition and subsequent detransition. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned. There are many different reasons and experiences leading to detransition. More research is needed to understand this population, determine the prevalence of detransition as an outcome of transition, meet the medical and psychological needs of this population, and better inform the process of evaluation and counseling prior to transition.

Discussion

This study was designed to explore the experiences of individuals who obtained medical and surgical treatment for gender dysphoria and then detransitioned by discontinuing the medications or having surgery to reverse the changes from transition. The findings of this study, however, should not be assumed to be representative of all individuals who detransition. Although this study further documents that detransitioners exist, the prevalence of detransition as an outcome of transition is unknown. Only a small percentage of detransitioners (24.0%) informed the clinicians and clinics that facilitated their transitions that they had detransitioned. Therefore, clinic rates of detransition are likely to be underestimated and gender transition specialists may be unaware of how many of their own patients have detransitioned, particularly for patients who are no longer under their care.

This research demonstrates that the experiences of individuals who detransition are varied and the reasons for detransition are complex. Nearly all participants identified as transgender or nonbinary at the start of their transition and most sought transition because they did not want to be associated with their natal sex, their bodies felt wrong the way they were, and they believed that transition was the only option to relieve their distress. Some were helped by transition and only detransitioned because they were pressured to do so by people in their lives, society, or because they had medical complications. Some were harmed by transition and detransitioned because they concluded that their gender dysphoria was caused by trauma, a mental health condition, internalized homophobia, or misogyny—conditions that are not likely to be resolved with transition. These findings highlight the complexity of gender dysphoria and suggest that, in some cases, failure to explore co-morbidities and the context in which the gender dysphoria emerged can lead to misdiagnosis, missed diagnoses, and inappropriate gender transition. Some individuals detransitioned because their gender dysphoria resolved, because they found better ways to address their symptoms, or because their personal definitions of male and female changed and they became comfortable identifying as their natal sex.

The study sample was predominantly young natal females, many of whom experienced late-onset gender dysphoria which mirrors the recent, striking changes in the demographics of gender dysphoric youth seeking care as well as the youth described by their parents in Littman (2018) (see also Aitken et al., 2015; de Graaf et al., 2018; Zucker, 2019). Concerns have been raised that this new cohort of gender dysphoric individuals is unlike previous cohorts. Professionals have started to call for caution before treating this cohort with interventions with permanent effects because the etiologies, desistance and persistence rates, expected duration of symptoms, and whether this new population is helped or harmed by gender transition is still unknown (D’Angelo et al., 2021; Kaltiala-Heino et al., 2018). The natal females and natal males in this sample differed on several dimensions, including that natal females were younger than natal males when they sought transition, when they decided to detransition, and at the time of survey completion. Natal females were more likely than natal males to have experienced a trauma less than one year before the onset of their gender dysphoria and were more likely to have felt pressured to transition. Compared to natal males, natal females remained transitioned for a shorter duration of time before deciding to detransition. Additionally, natal females transitioned more recently than natal males, so their experiences may vary due to changing trends in the clinical management of gender dysphoria and the cultural settings in which they became gender dysphoric.

The study findings covered a wide range of detransition experiences that are consistent with the diversity of experiences described in previously published clinical case reports and case series. Overlap of findings include: transition regret; absence of transition regret; re-identification with birth sex; continued identification as transgender; improvement or worsening of well-being with transition; retransitioning; detransitioning due to external social pressures; nonbinary identification; and recognizing and accepting oneself as homosexual or bisexual (D’Angelo, 2018; Djordjevic et al., 2016; Levine, 2018; Pazos Guerra et al., 2020; Turban & Keuroghlian, 2018; Turban et al., 2021; Vandenbussche, 2021). The population in this study is similar to the population in Vandenbussche in that both were predominantly natal females in their mid-20s. Because the current study recruited in 2016–2017 and Vandenbussche recruited in 2019, the similar mean age of participants may reflect the age of individuals who can be reached in online detransitioner communities. Several findings in this study were consistent with Vandenbussche’s findings, including similar reasons for detransition (realizing that their gender dysphoria was related to other issues, finding alternatives to address gender dysphoria, gender dysphoria resolved, etc.). Although these two studies were recruited in different years, had different eligibility criteria, and included participants from several countries, it is possible that there may be some overlap of study populations.

The current study findings provide additional insight into the complex relationships between internalized homophobia, gender dysphoria, and desire to transition. Contrary to arguments against the potential role of homophobia in gender transitions (Ashley, 2020), participants reported that their own gender dysphoria and desire to transition stemmed from the discomfort they felt about being same-sex attracted, their desire to not be gay, and the difficulties that they had accepting themselves as lesbian, gay or bisexual. For these individuals, exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration before making the decision to transition. This research adds to the existing evidence that gender dysphoria can be temporary (Ristori & Steensma, 2016; Singh et al., 2021; Zucker, 2018). It has been established that the most likely outcome for prepubertal youth with gender dysphoria is to develop into lesbian, gay, bisexual (LGB) (non-transgender) adults (Ristori & Steensma, 2016; Singh et al., 2021; Wallien & Cohen-Kettenis, 2008; Zucker, 2018). And, temporary gender dysphoria may be a common part of LGB identity development (Korte et al., 2008; Patterson, 2018). Therefore, intervening too soon to medicalize gender dysphoric youth risks iatrogenically derailing the development of youth who would otherwise grow up to be LGB non-transgender adults. Participants who detransitioned because they became comfortable identifying as their natal sex and because their gender dysphoria resolved further support that gender dysphoria is not always permanent.

The data in this study strengthen, with first-hand accounts, the rapid-onset gender dysphoria (ROGD) hypotheses which, briefly stated, are that psychosocial factors (such as trauma, mental health conditions, maladaptive coping mechanisms, internalized homophobia, and social influence) can cause or contribute to the development of gender dysphoria in some individuals (Littman, 2018). Littman also postulated that certain beliefs could be spread by peer contagion, including the belief that a wide range of symptoms should be interpreted as gender dysphoria (and proof of being transgender) and the belief that transition is the only solution to relieve distress. The current study supports the potential role of psychosocial factors in the development of gender dysphoria and further suggests, by participant responses that transitioning prevented or delayed them from addressing their underlying conditions, that maladaptive coping mechanisms may be relevant for some individuals. The potential role of social influence is demonstrated as well. First, when respondents were asked to describe how they currently feel about having identified as transgender in the past, more than a third endorsed the option, “Someone told me that the feelings I was having meant that I was transgender, and I believed them.” Second, a subset of participants experienced the unique friendship group dynamics reported in Littman where peer groups mocked people who were not transgender and popularity within the friend group increased when respondents announced their plan to transition. Additionally, respondents identified several social sources that encouraged them to believe that transitioning would help them including: YouTube transition videos, blogs, Tumblr, and online communities. And finally, 20.0% of participants felt pressured to transition by social sources that included friends, partners, and society. More research is needed to further explore these hypotheses.

The current study and the Turban et al. (2021) analysis of the USTS data share some similarities and differences. Similarities include the use of convenience samples, targeted recruitment, and anonymous data collection. The findings of Turban et al. (including external pressures to detransition and transgender identification after detransition) are a subset of the array of experiences described in the current study. The current study differed from James et al. (2016) and Turban et al. in that it enrolled participants based on the criterion of detransition after medical or surgical transition regardless of how they currently identified, recruited from communities with diverse perspectives about transition and detransition, used a precise definition for detransition that specifies the use of medication or surgery, and included answer options that were relevant to many different types of detransition experiences. In contrast, the USTS only enrolled transgender-identifying individuals regardless of whether they medically or surgically transitioned, recruited from communities likely to have similar perspectives about transition and detransition, and provided multiple choice answer options that were relevant to a narrower range of detransition experiences (James et al., 2016). Further, the definition used by the USTS for “detransitioned” (having “gone back to living as [their] sex assigned as birth, at least for a while”) is quite vague. Although Turban et al. provide valuable information about the subset of transgender-identifying people who may have detransitioned, the current study provides a more comprehensive view of individuals who detransition after medical or surgical transition.

Over the past 15 years, there have been substantial changes in the clinical approach to gender dysphoric patients notable for a shift from approaches that employ thorough evaluations and judicious use of medical and surgical transition (the watchful waiting or Dutch approach, the developmentally informed approach, and the medical model of care) to approaches with minimized or eliminated evaluation and liberal use of transition interventions (the affirmative approach and the informed consent model of care) (Cavanaugh et al., 2016; de Vries & Cohen-Kettenis, 2012; Meyer et al., 2002; Rafferty et al., 2018; Schulz, 2018; Zucker et al., 2012b). This trend is prominent in the U.S. where the American Academy of Pediatrics endorsed the affirmative approach in 2018 and Planned Parenthood currently uses the informed consent model to provide medical transition in more than 200 clinics in 35 states (Planned Parenthood, 2021; Rafferty et al., 2018). It is plausible that an unintended consequence of these clinical shifts may be an increase in people who detransition. Many participants in this study believe that they did not receive an adequate evaluation by a clinician before transition. The definition of “adequate evaluation” was not provided in the survey and may be open to respondent interpretation. But given the complexities of the gender dysphoria described in the current study, one might consider a low bar of “adequate” to be the exploration of factors that could be misinterpreted as non-temporary gender dysphoria as well as factors that could be underlying causes for gender dysphoria. The most recently emerging approach to gender dysphoria is called the “exploratory approach” which is a neutral psychotherapeutic approach to help individuals gain a deeper understanding of their gender distress and the factors contributing to their dysphoria (Churcher Clarke & Spiliadis, 2019; Spiliadis, 2019). The study’s findings suggest that an exploratory type of approach may have been beneficial to some of the respondents. Future research is needed to determine which patients are best treated by which approaches long term.

Patients considering medical and surgical interventions deserve accurate information about the risks, benefits, and alternatives to that treatment. In this sample, nearly half of the participants reported that the counseling they received about transition was overly positive about the benefits of transition and more than a quarter reported that the counseling was not negative enough about the risks. Several participants felt pressured to transition by their doctors and therapists. If these types of clinical interactions are verified, exploration is needed to determine the extent to which this situation occurs and what measures might be taken to ensure that clinicians provide patients with their options accurately and dispassionately.

There are several obstacles to obtaining accurate rates of detransition and desistance, including stigma and the low numbers of detransitioners who inform their clinicians that they detransitioned. One approach to bypass some of these barriers would be to incorporate non-judgmental questions about detransition and desistance into nationally representative surveys that collect health data. For example, the Behavioral Risk Factor Surveillance System contains an optional module about sexual orientation and gender identity that includes two questions to explore gender issues (Downing & Przedworski, 2018). By changing one existing question, “Do you consider yourself to be transgender?” into two questions, “Have you ever, at any point in your life, considered yourself to be transgender?” and “Do you currently consider yourself to be transgender?” and by adding a follow-up question if answers indicate past but not current transgender identification, “Did you ever take puberty blockers, cross-sex hormones, anti-androgens, or have any surgery as part of your transition?”, valuable information about desistance, detransition, and current transgender identification could be obtained. These types of questions may also be of use in clinical practice and electronic medical records. The information gained about rates of detransition and desistance would enhance transgender healthcare by aiding informed consent processes at the start of any medical or surgical transition.

One of the strengths of this study is that it is one of the largest samples of detransitioners to date. Other strengths include the use of a precise definition for detransition, enrollment of detransitioners regardless of their post-detransition gender identification, recruitment from communities with likely divergent views about transition and detransition, and collaboration with two individuals who had detransitioned which helped to create a survey instrument with questions relevant to a variety of detransition experiences and enhanced the recruitment efforts.

There are several limitations to this study that should be considered when interpreting the findings. Like Vandenbussche (2021), James et al. (2016), and Turban et al. (2021), this study used a cross-sectional design, anonymous surveying, and a convenience sample and therefore shares the same limitations that are inherent to these methodologies. These limitations include that conclusions about causation cannot be determined, identities of participants cannot be verified, and the findings of this study may not be generalizable to the entire population of people who detransition or to people outside of the countries where participants were from. Although this study reached out to communities with differing perspectives about transition and detransition, targeted recruitment and convenience samples always introduce the limitations associated with selection biases which should be addressed in future research. Finally, many of the participants in this study had less than ideal outcomes to their medical and surgical transitions, and it is possible that these experiences may have colored some of the responses.

Additional research is needed to determine the prevalence of detransition as an outcome of transition and to identify and meet the psychological and medical needs of the emerging detransitioned population. Because many individuals who detransition re-identify with their birth sex, are no longer connected to LGBT communities, and don’t return to gender clinics, future research about detransition needs to expand recruitment efforts beyond gender clinics and transgender communities. The development and testing of non-medical interventions for gender dysphoria could provide valuable options to be used as alternatives or in conjunction with medical and surgical treatments. Because of the potential for some to experience trauma, mental health conditions, internalized homophobia, and misogyny as gender dysphoria, research needs to be conducted on the evaluation process before transition to find approaches that respectfully and collaboratively explore factors that might contribute to gender-related distress. There continues to be an absence of long-term outcomes evidence for youth treated with medical and surgical transition and a lack of information about the trajectories of youth experiencing late-onset gender dysphoria–research is needed to address these gaps. Continued work is needed to reduce rigid gender roles, increase representation of gender stereotype nonconformity, and to address discrimination and social pressures exerted against people who are transgender, lesbian, gay, bisexual, and gender stereotype non-conforming.