We Need to Change the Terms of the Debate on Trans Kids
Every night, when I walk my dog, several strangers, similarly tethered, will ask me the same two questions: “Boy or girl?” and “How old?” The pragmatic meaning of these questions escapes me. The answers do not inform the interactions between our dogs, nor do they tell a story. Wouldn’t it be more interesting to learn whether the dog was a longtime family member or a pandemic puppy, whether it lived with other pets, how much exercise it got or desired, how it tolerated last summer’s orgy of fireworks, or to learn at least the dog’s name? These are the questions I usually ask other dog owners as our pets sniff each other, but in response I am still asked—hundreds of times a year—about my dog’s age and gender. These categories, it seems, are so central to the way we organize the world around us that we apply them to everything, including random dogs in the night.
No wonder, then, that attempts to subvert these two categories make people uncomfortable and, often, scared and angry. This happens when children act with particular independence; when people challenge the norms of gender; and, especially, when both of these things happen at once, as in the case of trans children. In December, the British High Court of Justice ruled on the question of whether young people under the age of eighteen are capable of giving informed consent to treatments that forestall puberty. Such treatments can be prescribed to children given a diagnosis of gender dysphoria, both to alleviate discomfort that can stem from the physical changes brought on by puberty and to pave the way for later medical gender transition. The court ruled that children under sixteen cannot consent to such treatment because they are unable to grasp its long-term consequences, and cast doubt on the ability of young people between the ages of sixteen and eighteen to give informed consent. The decision effectively bars British children and adolescents from transitioning medically.
British media coverage of the High Court’s decision was generally positive. “Other countries should learn from a transgender verdict in England” the Economist wrote. “The court was correct to curb a disturbing trend,” the Observer wrote. Later in the month, the BBC’s media editor, Amol Rajan, published his list of the five best essays of the year, among them J. K. Rowling’s piece explaining her position “on sex and gender issues.” Rowling, who presents herself as a defender of bathrooms, dressing rooms, and other “single-sex spaces” against trans women, wrote that she was “concerned about the huge explosion in young women wishing to transition and also about the increasing numbers who seem to be detransitioning.” She cited the controversial hypothesis that some adolescent transitions may stem from a kind of social contagion. Had transition been an option during her own adolescence, Rowling wrote, she might have chosen it as a way to deal with her own mental-health challenges: “The allure of escaping womanhood would have been huge.”
In the United States, this line of argument has been advanced by Abigail Shrier, a writer for the Wall Street Journal who published a book last year titled “Irreversible Damage: The Transgender Craze Seducing Our Daughters.” The cover art is a drawing of a prepubescent girl with a giant round cutout where her abdomen should be. The book is currently ranked “#1 Bestseller in Transgender Studies” on Amazon. Bills that would ban trans care for young people have already been prefiled for this year’s legislative sessions in Alabama, Texas, and Missouri; last year, a similar bill was defeated in South Dakota, thanks to opposition from the pharmaceutical industry. When such bills contain language explaining their rationale, they make similar arguments to those of Rowling, Shrier, and the British High Court: that the effects of trans care are irreversible and that many people who want to transition when they are adolescents will ultimately choose to identify with the gender they were assigned at birth.
The state bills tend to lump all kinds of trans care—puberty blockers, cross-sex hormones, and surgeries—together. As a narrative, this is not unreasonable: the vast majority of people who receive puberty blockers do go on to take cross-sex hormones, and many choose surgery. But the short- and long-term effects of the medical interventions are markedly different. Agonists of gonadotropin-releasing hormone, originally developed to treat prostate cancer and endometriosis in adults, can have the effect of preventing puberty-related changes: genital growth, breasts, body and facial hair, and voice changes. Estrogen promotes breast growth, and testosterone will likely lead to a lower voice and more body and facial hair; both kinds of hormones affect fat and muscle distribution. The effects of hormones are not as predictable—and the line between reversible and irreversible effects of hormone treatments isn’t as clear—as their opponents seem to think, but a person whose puberty is effectively prevented and who later receives cross-sex hormones is unlikely to preserve their fertility. Some European researchers are experimenting with reserving gonad tissue that may be used to create biological progeny later (similar efforts are made with children undergoing cancer treatment that is likely to render them infertile). Natal males and females who transition during adolescence forfeit their fertility equally, but Rowling, Shirer, and other opponents of pediatric trans care seem particularly concerned with people they see as girls clamoring to escape womanhood. (The lead plaintiff in the British case, Keira Bell, who was assigned female at birth, began taking puberty blockers at sixteen and testosterone at seventeen and had a double mastectomy at twenty. Bell later transitioned back to being female.)
“Women and children are always mentioned in the same breath,” the visionary feminist activist Shulamith Firestone observed in the book “The Dialectic of Sex: The Case for Feminist Revolution,” from 1970. “I submit . . . that the nature of this bond is no more than shared oppression. And that moreover this oppression is intertwined and mutually reinforcing in such complex ways that we will be unable to speak of the liberation of women without also discussing the liberation of children, and vice versa.” Firestone noted that women and children were inextricably linked not only by the women’s duty of childbearing and child rearing but by the obligation, for both groups, to maintain innocence, fragility, immaturity, and dependence on others. She saw the path to liberation in divorcing the reproductive function from women’s biology, and in abolishing childhood. One might argue that young people who seek trans care are pursuing both of these projects, and that is why they inspire such panicked opposition.
Yet the arguments in favor of trans care for young people are usually not so much liberationist as they are determinist. Advocates generally claim that trans children are innately, immutably different from cis children and that access to medical transition is essential for staving off depression and even suicide. “The fear that puberty per se can be a threat to life for transgender children permeates pediatric trans care,” Sahar Sadjadi wrote in an essay in Transgender Studies Quarterly last year. (Sadjadi is a medical anthropologist who has studied clinical practices for transitioning and other non-gender-conforming children for a decade.) This type of advocacy, she argues, builds on two long-standing tendencies: the habit of thinking of gender transition as primarily a medical process, and the habit of grounding L.G.B.T. civil-rights claims in “born this way” rhetoric. These habits make for a compelling, easily digestible argument: transness is an immutable characteristic, and denying young people access to medical transition can be tantamount to killing them. This argument is grounded in the lived experience of some advocates, whose own medical transition relieved extreme anguish. But an argument rooted in despair cannot and should not represent all young trans people.
When we are not talking about children and adolescents, trans people talk about a much broader range of options than medical transition—a spectrum of gender expression more varied than the linear path of puberty blockers followed by cross-sex hormones. Some adult trans people consider themselves binary, and some don’t; some use hormones and have surgeries, some choose one or the other, some try different approaches, and some eschew medical interventions altogether. Medical intervention requires a diagnosis of gender dysphoria, even if the person is paying for surgery and hormones out of pocket. In general, though, adults are not required to prove that they have always felt like they were in the wrong body (although some have).
If we hold to the premise that transness is an immutable, inborn trait, it follows that every young person who chooses to detransition will undermine the case any other young person may have for seeking trans care. “The main debate has become whether these young people will ‘persevere,’ ” Sadjadi told me by Zoom from Montreal, where she is on the faculty at McGill University’s Department of Social Studies of Medicine. “I think this is the wrong question. Gender changes with age. The gender of a fifty-year-old woman is not the same as of a five-year-old girl. Nothing terrible happens if a person transitions again, which is how I think we should think about it.”
The British High Court’s decision makes a point that appears compelling and compassionate. A child, the panel decided, cannot fully comprehend the meaning of infertility and possible loss of sexual function that come with transitioning at a young age. (One concern is that puberty blockers prevent genital growth, making gender-affirming bottom surgery more complicated.) But this argument rests not only on a narrow definition of sexual pleasure but on an impossible ideal of comprehension: we can never fully imagine loss, especially the loss of something we’ve never had. Keira Bell testified, “It is only until recently that I have started to think about having children and if that is ever a possibility, I have to live with the fact that I will not be able to breastfeed my children. I still do not believe that I have fully processed the surgical procedure that I had to remove my breasts and how major it really was.” As heartbreaking as that admission is, all available data indicate that such regrets are exceedingly rare. That one person’s testimony convinced the court to make a decision that will affect untold thousands tells us more about the pull that human reproduction has on the imagination than it does about gender transition.