In Jesse Singal’s controversial 2018 cover story for The Atlantic, “When Children Say They’re Trans,” the writer invoked regret eight times. It appeared in the story of a young person who almost transitioned but didn’t, in a doctor’s analysis of the risk and reward of such procedures, and ultimately in Singal’s own note of warning. While many adolescents may suffer from the denial of care, “some teenagers, in the years ahead, are going to rush into physically transitioning and may regret it,” he concludes.

Singal’s story was widely criticized by trans individuals, advocacy organizations, and allies for its fear-mongering approach to an urgent human rights issue. “Transitioning is an effective medical treatment that improves millions of lives,” Alex Barasch wrote in Slate at the time. “Why are we so fixated on the few who regret it?”

Yet the mere possibility of regret remains an enduring motif in medical decision-making—particularly where interventions threaten normative assumptions about sex, gender, and sexuality. That means birth control, elective sterilization, abortion, trans health care, and treatments for cancers of the reproductive organs remain under constant scrutiny.

Some health care providers decline to perform services under the conscience clause; others go a step further and support attempts to restrict or ban these procedures at the state or national level. More often, though, hospitals and clinics simply try to head off regret by instituting waiting periods, sometimes weeks or even months long, and extensive counseling sessions prior to such procedures—a softer form of gatekeeping, but one that can nonetheless present a significant barrier to access.

This is all despite anecdotal and empirical evidence that consistently contradicts popular narratives of medical regret. In the US, for example, there is an assumption that regret, trauma, and mental health issues are common side effects of abortion. But longitudinal studies have found that five years after the procedure, 95 percent of abortion recipients—an overwhelming majority—believe it was the right decision for them.

The debate about whether regret is possible is easy enough to resolve: Regret is always possible, whether you act or you don’t. But this has so far obscured a more fundamental question: To what extent should regret be a factor in medical decision-making in the first place?

The psychological consequences of a prescription or procedure may be relevant to a patient’s understanding of the risks they are undertaking, but the emphasis on anticipatory regret often “allows a lot of values or political views to be projected into that future,” says Jacob D. Moses, a postdoctoral fellow in the history of medicine and public health at Johns Hopkins University.

For regret is the price of freedom. In exercising autonomy, a person must accept that there could be consequences they cannot adequately calculate in the moment. This is no less true when it comes to health. To find support in forging ahead anyway is an exercise in the dignity of risk, a term coined by disability rights activist Robert Perske to push back against the overprotection of the elderly, the mentally ill, and the developmentally disabled, whose autonomy is often limited “for their own good.” In the face of persistent medical paternalism, such dignity must be articulated for all.

Historically, physicians made decisions on behalf of their patients. That changed over the course of the 20th century, as the principle of informed consent took hold in medicine, and patients gained more control over their own bodies.

At the same time, medicine was becoming not only life-saving but life-enhancing, and Americans in particular began to see themselves as savvy consumers of such medicine, as opposed to passive recipients of expert care. The study of regret, which was first advanced in behavioral economics and then seeped into other fields, including medicine, promulgated the model of loss aversion, in which the mere possibility of loss can often overshadow likely gains. Now doctors intent on denying procedures such as abortion and sterilization for other reasons could point to a grander theory of medical regret.

This interest in regret is still apparent in clinical settings today. Researchers who want to understand the psychological effects of different medical interventions often use the Decision Regret Scale, which asks people to rate five simple statements, like “It was the right decision” and “The choice did me a lot of harm” on a scale from one (strongly agree) to five (strongly disagree). The more points a person racks up, the more they supposedly regret their decision. But the lived experience of regret is never so simple.

For one, regret can change over time, just like people do. The word contains multitudes, from guilt to resentment to curiosesity. And new experiences can give old decisions new meaning. For example, in the US there remains a largely unfounded fear that having an abortion can hinder future fertility; a person who “regrets” their abortion for this reason may no longer do so when they choose to give birth to a child later in life and are able to.

Despite the current popularity of the “no regrets” mantra, reflecting on past mistakes can also help people define their values and make better decisions in the future. “This thing that is everywhere doesn’t feel good—why is that?” says Daniel H. Pink, author of a recent book called The Power of Regret: How Looking Backward Moves Us Forward. “The scientific answer is, it serves a purpose.” To Pink, regret offers clarity, insight, and instruction.

Perhaps most importantly, regret can be culturally constructed, even if it feels deeply personal. What a person regrets—and what they don’t—is shaped by shared values and a sense of acceptance from friends, family, or community. A decision may do someone “a lot of harm” not because it was wrong for them, but because those around them disagreed with it.

That appears to be the case for the 34 women sociologist Carolyn Mackelcan Morell interviewed for her 1994 book, Unwomanly Conduct: The Challenges of Intentional Childlessness. Morell found that these women did not experience regret over their decision. Rather, they shared “‘wistful’ feelings, or unsettling ‘rumblings,’ or ‘twinges’ of doubt, or ‘passing thoughts’ about the road not taken.” These feelings were acceptable to the women, and often easily managed.

But the persistence of such thoughts among Morell’s participants shows how the mere threat of regret can make even the most determined people question their convictions. No matter how assured these women were in their choice, they still had to face ongoing societal pressure to conform. “Some women seem to be impervious to popular beliefs about not-mothering as incomplete, as inadequate, as having inferior lives,” Morell, who was herself childless, wrote. “For me, being childless requires a measure of courage.”

Discussions of regret are only further complicated by age. Many Americans still believe in “because I said so” parenting, says Paul Lombardo, a medicolegal historian at Georgia State University. A person under 18, unless formally emancipated or having otherwise obtained the support of a court, will struggle to find legal means to pursue medical interventions (including contraception, abortion, STI and HIV treatment, mental health care, and substance abuse treatment) without their guardian’s consent.

That poses a particular challenge for adolescents, who may be under 18 but still have the ability to reason through complex decisions when presented with the relevant information. In such cases, pediatricians have typically argued that children should be able to override a parent’s medically unsound decision, such as vaccine refusal, as young as 12. But decisions where medical guidance is contested, or the consequences are permanent, are often more contentious, and doctors must ultimately defer to the laws of their state, which vary widely.

It’s ironic, then, that many Americans have taken issue with trans youth’s pursuit of puberty blockers, which suppress hormones like estrogen and testosterone to temporarily delay breast development, a deepening voice, or other secondary sex characteristics. While an adolescent’s access to these drugs is typically restricted in the absence of parental support—or, in states like Texas, potentially even with parental support—these young people are pursuing the very thing regret-sensitive gatekeepers recommend: time to think before making more permanent decisions.

In highly politicized cases, even legal adulthood is not enough to guarantee access to desired health care. In the 1960s, for example, gynecologists held that for a woman—particularly a white woman—to receive elective sterilization as a permanent form of birth control, her age multiplied by her existing children must add up to 120. While the “120 rule” is no longer in effect today, it still influences health care providers, who routinely deny this legal procedure to women in their 20s on the premise that they’ll eventually “change their minds.”

But the exceptions to the rule illuminate the real motives here. Notably, the 120 rule never applied to men. And while white women’s fertility was protected even at the cost of their sovereignty, doctors have often sterilized women of color, women with disabilities, and incarcerated women against their will—a particularly flagrant violation of patient autonomy.

In many cases, citing regret and denying treatment “is not about the medical danger. This is not about regret,” Lombardo says, particularly in cases where age and marginalized racial or gender identities intersect. “This is about someone saying, ‘I have the power to stop you from doing something I think is morally terrible.’”

Today, medical school students are unlikely to formally encounter the concept of medical regret, even as the experiences of women, nonbinary, and trans people suggest that these future doctors will invoke the idea in practice. Rather, medical trainees are drilled in the models of informed consent and shared decision-making, in which the patient and the provider agree on treatment decisions together.

These mechanisms may be a “prophylactic for future regret,” Moses says, but they have also become a way of managing a physician’s legal or moral liability once they have already agreed to carry out a procedure. This suggests that regret as a reason to deny treatment is bubbling up from gender norms, medical paternalism, and other sources—and will require other solutions.

To remove the undue burden of regret on patients pursuing gendered health care, one proposal might be to simply universalize the issue. By generating empirical data on regret for all surgical interventions, from coronary bypass surgery to cosmetic breast augmentation, and alerting people regardless of gender or age to the possibilities, doctors could invoke regret equally.

Generating this kind of data would be an enormous undertaking, but some investigations are already underway. Moses, for example, is currently collaborating on research regarding the ethical considerations in treating dystonia, a movement disorder, in kids using deep brain stimulation. Regret is one of the outcomes the team is measuring. Once the results are in, doctors might be able to use that data to inform future families about the potential emotional or psychological consequences of their decisions.

But the problem of study design remains: In offering a fairly simplistic account of regret, and in the time-limited duration of a study, regret scales are likely to miss out on much of the material reality of a patient’s life. This is especially true in cases where children or adolescents are the ones who receive or are denied a given medical intervention but their caregivers are the ultimate decision-maker. For each member of a family unit, regret (or its absence) may play out differently.

Another option might be to formulate a fundamental right to regret and teach it in medical schools. It’s an idea I’ve been mulling over since I spoke to Lombardo, the legal expert, five years ago as part of an audio project on elective sterilization. There’s some precedent here in consumer protection law, which builds in a cooling-off period so goods can be returned or contracts terminated. Of course, medical procedures often cannot be undone, but a similar pause is already built into the informed consent process, which asks a patient to weigh their decision carefully—in most cases, over the course of 20 minutes, not two years. Crucially, a “right to regret” model could ask for a similar pause on the part of doctors by building into their practice regular reminders to reflect on why they’re concerned about regret, what the data (where it already exists) actually shows, and what other emotions might be relevant to the well-being of their patient.

Regret should not have any special claim to prominence in medical decision-making or be emphasized over other equally theoretical emotions. When someone decides to undergo a procedure, “one of the possibilities of that is regret—so is relief, so is happiness,” says Dianne Lalonde, a political theory PhD candidate at Western University in Canada and the author of a paper on elective sterilization. In practice, this might mean that doctors wouldn’t talk about regret at all—or, if they did, they would inform patients about other, better outcomes, too.

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