In defense of trans quality of life
Today, trans people exist in an atmosphere where it has become normal for strangers to demand of us that we extemporaneously provide inarguable, indisputable proof that without very safe medical care we would be stone-cold dead.
It happens at random. At work, at school, on the subway. In our inboxes. Every day we are besieged by people who feel entitled to seek us out in vulnerable places and demand an audience. Suddenly, everyone with the ability to make a social media account believes they are an expert in what has always been a highly specialized and technical field, even within the larger field of medicine itself.
They insist that inclusive of certain prevention of total loss of life, the medical care we rely upon to live normal, healthy lives must also be devoid of side-effects and tradeoffs. They want a flawless recovery into a remunerable future full of improbable success and better than average mental heath, and the popular press has made itself resoundingly clear that this is the only threshold upon which our care will be judged acceptable to administer. And while It's important to establish that gender-affirming care is indeed life-saving, it is also important to say that what it provides is more than simply an antidote to a slow motion death.
what it provides is more than simply an antidote to a slow motion death.
When people hear "it saved my life", there’s a presumption made that we mean without it we would quite literally die. And for many of us, that's absolutely true. When the few people who've thought to ask me in good faith have done so, I explain that for me personally it literally saved my life.
But for those of us who rely upon it regularly regardless of such a possibility, it also means more than simply living. It means our lives are made so much better now that they actually feel worth living — that the change that gender-affirming care makes possible isn't just about life or death, it's about a vibrant life instead of the absence of one. Not only a life, but a one that exists unflinchingly in full color, with all the flavor and the volume turned up. Today I live a life that I fight tooth and nail to protect, and work daily to make possible for others so that no one should ever have to choose differently.
The truth is that nowhere in medicine do we insist that the only function of an intervention must be that such an intervention would be the only thing keeping us from certain death. That's not, to put it simply, how medicine works. In reality, the average person may take a dozen medications in a year that relieve headaches, upset stomachs and acid reflux, persistent cough, and congested sinuses. While there is some emerging evidence that ADHD medications are linked longitudinally with decreased mortality related to events like car accidents and workplace injuries (as well as through indirect pathways like increased health-seeking behaviors) there is little evidence to show that in the immediate, medications for inattentiveness are linked to prevented immediate loss of life. Asthma can absolutely be life-threatening, but it can also be mild enough for some people such that it never poses a lethal threat unless specific conditions are met Nowhere do we suddenly throw up our hands about the “overprescription” and distribution of inhalers.
Loss of life has never been the basis of argument for most medications, and it shouldn’t be. Were such a criterion to be enforced, we would likely need to abandon the majority of therapeutics used in primary care. Psoriasis itself cannot kill, yet many of the indications for Humira (adalimumab), are also its known and documented side effects. We allow people to make this choice in concert with their physicians because we know that the ability to do so has a tremendous effect on quality of life.
Quality of life is the basis for most of medicine. We recognize that the ability for a patient with myalgia to dance is unlikely to save their lives, but that the ability to do so has inherent value on the basis that the patient themselves and the richness of the lives such interventions enables forms the basis for that value. The argument for gender-affirming care has never been solely about its ability to stop death, it’s about the way it helps us build the lives we deserve. The argument for affirmation is that no one should be deprived of the opportunity to live their lives in such a way as feels the most true to who you are, free from boundaries easily removed by modern medicine. This is not, as so many reactionaries like to claim a transhumanist goal, it is a humanistic one. It’s why we make glasses and hearing aids — not to live some artificial, augmented reality, but to most fully participate in the one in which patients currently live.
This is also to say nothing of the medications taken specifically for gender-affirmation that are nonspecific to transgender people: such as medications to prevent the thinning of the hair or the restoration of libido. Also included in this category would be medications to clear up the skin, build body mass, even to make us grow taller. The modulation, prevention and induction of puberty is not solely or even primarily the domain of transgender children. While gonadotropin-releasing hormone agonists (eg. puberty blockers) are primarily used for blocking precocious puberty, growth hormone analogs and even endogenous testosterone are sometimes used for its induction. Testosterone now enjoys a fairly substantial heyday among adults as well, with even arch anti-trans pundits like Joe Rogan proudly taking HRT.
A recent study of medical claims in the United States showed that this wasn’t restricted to non-surgical interventions either. In fact, the number of gender-affirming procedures for cisgender minors vastly eclipses the number of similar procedures for same-age transgender patients when we expand the paradigm to include surgery for gynecomastia, or even cosmetic rhinoplasty compared to facial feminization done for transfeminine patients. The idea of gender-affirming care is neither remotely new nor restricted to gender diverse people. To pretend otherwise is mendacity. And yet today, many of these procedures are banned for transgender youth while still being accessible to cisgender minors. It is harder for transgender young people to get chest or facial surgery than it is for their peers.
There is also no corresponding legislative ban of psychiatric medications with a far more expansive array of irreversible side effects like tardive dyskinesia, used to treat conditions which themselves do not involve any threat to the “healthy body” as Gender Critical rhetoric is so fond of calling it. That isn’t to say they should therefore be thusly regulated. This is precisely the point: medical decisions should be made solely by medical professionals and their patients.
When the first pediatric top surgeries began being performed, they were done because the patients who sought them had otherwise dropped out of public life. The Chest Dysphoria Scale, rather than measure some slightly more esoteric sense of congruence between the self and the body, measures rather the effects of that congruence or lack thereof on the very real daily lives of young people. As Mehringer found in qualitative interviews, many youth put their entire lives on pause before top surgery. Many had dropped out of school or were recorded as truant, others had foresworn romantic relationships and friendships. Most in the cohort used to test the validity of the CDS had stopped swimming or going to the beach, many of them stopped going to doctors. The overwhelming majority stopped using public changing facilities and avoided school athletics. A significant majority stopped showering or bathing.
These difficulties evaporated after surgery, and many went on to find that the things they had so strenuously avoided were actually that which gave them the most joy post-operatively. They now live rich lives full of health-promoting behaviors like medical care, exercise, and participation in their studies and public life. Few singular interventions offer this much lasting positive impact. From the 2021 paper:
“It was liberating, because I just could finally live a normal life like the rest of kids my age.… [It’s] a lot easier to talk to people because I’m not as uptight, or I don’t come off as rigid as I was. So, it’s made me a lot more relatable to people because I could actually – I don’t have to worry about my chest dysphoria.” (A.C.)
“It’s been a relief.… Now that the problem is basically solved…I can basically focus the energy that I was focusing on [my chest] and redirect it somewhere way more productive.… I can now do actual exercise for the first time in my life.” (D.V.)
Jamie E. Mehringer, Jacqueline B. Harrison, Kit M. Quain, Judy A. Shea, Linda A. Hawkins, Nadia L. Dowshen; Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics March 2021; 147 (3): e2020013300. 10.1542/peds.2020-013300
Since suddenly our opponents are deeply interested in “evidence”, what evidence do they have for an alternate intervention that would bring truant children back to school, the doctor, and to gym all at once in the span of the three weeks? As someone who was herself a perpetually truant child in high school, and has spent nearly fifteen years working with children facing similar challenges, I can say categorically that there is no other intervention for this problem that has this level of success. Intensive wrap-around services developed for children experiencing truancy measure success by hours in the classroom, not days or weeks, let alone an immediate return to normal life. This is in part because truancy is a product of hundreds of interlocking factors, from learning styles to social anxiety, bullying and drug use. Rarely do we see it as the product of a singular cause, and when we do, we attack that singular cause with literally whatever we have at our disposal. There is no legitimate reason that this logic should fail simply because the student in question is not cisgender.
For as much as there may be truths with which we need to wrestle about the imperfection of our care as it’s currently delivered, our opponents have absolutely nothing of substance to offer for the hundreds or thousands of youth described above. When opponents state that certain procedures must not be made available under any circumstances due to a longitudinal possibility for regret, we gloss over the lifetime of regret caused by social isolation during the most formative years.
By seeing inaction as the neutral option, we ignore the fact that no evidence thus published in the history of medicine has ever found that more people regret hormone therapy or even surgery than those who do not, with the majority reporting high levels of satisfaction and dramatic improvements in quality of life. By extension, when we protect the small minority of patients for whom this care does not offer relief by prohibiting access to all patients for whom it will, we necessarily place primacy over one type of pain relative to another. If we have the capacity to relieve the burden of extraordinary numbers of people, what right do we have to withhold it? And what argument can be made that would not also extend to any number of commonly used therapeutics readily and uncontroversially deployed in the clinic?
When we protect the small minority of patients for whom this care does not offer relief by prohibiting access to all patients for whom it will, we necessarily place primacy over one type of pain relative to another.
While the world threatens to plunge us back into the dark ages, we live in miraculous times as well, for I have met a not-insignificant number of people for whom dysphoria is now a distant, albeit persistent memory. For the younger trans people who have had access to blockade and a gender-congruent transition concurrent with their cisgender peers going through their own puberty, a whole range of experiences are made possible by an upbringing uninterrupted by what many older trans people live their whole lives trying to reconcile. Gone are the days where a childhood of missing developmentally appropriate milestones is an inevitability.
When Jessica Norton made the news as a result of the Broward County Schools’ relentless pursuit of her and her family, one small footnote in the the uproar about her participation in girls’ volleyball told the story of a rich, fulfilling childhood full of social and academic success. Jessica was a homecoming princess and twice elected class president. Far from the picture of shy, anxiety-riddled youth painted by demagogues, Jessica prior to the public campaign lived a life perhaps fuller than most. And while the consequential campaign to ruin her life is one of the most abhorrent examples of conservative’s deeply unwell and relentless fixation on eliminating trans joy, the life she lived previously was a miracle made possible by early and safe intervention.
For no matter how many cautionary hypotheticals anti-trans crusaders can bring to the table, they cannot eliminate the simple fact that joyful trans childhoods do now exist, and in increasing numbers. She, and young people like her who live rich and fulfilling lives as a result of care safely delivered through a rigorous consent process involving a team of her, her parents, medical, and mental health professionals deserve to live those lives. It will take a hell of a lot more than any argument thus put forward to justify why she alone should be deprived of that life to satisfy the anxiety of those uninvolved in her care — or her life.
We also clearly do not prevent young people in other circumstances from making choices that carry risk. Despite being objectively dangerous and relevant to only a small number of students, football spending in many schools outpaces spending on learning in math and science. This is despite the fact that the game often leaves young people concussed, with destroyed knees, limited mobility. Some are left paralyzed, or sustain traumatic brain injuries and experience lifelong cognitive effects that no number of puberty blockers could ever claim to compete with.
Whereas young trans people in my generation struggled daily with the knowledge that a whole life of lost opportunities awaited us regardless of the choices we made, young people today in the few remaining parts of the country able to access gender-affirming care are able to choose fulfilling, affirmed lives without the sacrifices previously so inherent in transition. Many young people who transition early tell me that being trans is the least interesting thing about them; many of their peers don’t know, and the ones who do don’t care.
The ability to relegate one’s sex assigned at birth to an inconsequential, incidental characteristic feels to older trans people like alchemy. Trans children deserve to live those lives just as much as anyone else, and no one who attempts to justify withholding transition care appears to have an answer for why this should be any different.
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“Finally, I’ll finish as I began. Congratulations for choosing the conditions of your own existence and survival when no one else ever showed you how. You bossed the hardest dillema of all: whether to live. Remember Hamlet? ‘To be or not to be - that is the question.’ There’s a reason it’s one of the most famous lines ever written, hun. You chose to be. You are going to be fine.”
— Shon Faye
Faye, S. (2018) Shon Faye. In Craggs, C. (2018). To my trans sisters. Jessica Kingsley Publishers.
