The Liberal Retreat on Trans Medicine

Paternalism, risk, and Isaiah Berlin

If you’re reading me, there’s a very good chance you’ve already read Andrea Long Chu’s New York Magazine essay about the moral right of transgender minors to medical gender transitions. The piece treads familiar ground to anyone who has read much of anything about trans studies going back to at least the 1970s, setting aside the pathologized version of gender-affirming care as a treatment for gender dysphoria and embracing a vision of self-determination and “biological justice” that includes unfettered access to these treatments on the basis of informed consent.

But for many, it was likely their first introduction to an argument that’s been unfolding between trans people and the medical establishment for the better part of a century. That certainly seems to be the case for Jonathan Chait, also of New York magazine, who published a “liberal” response. While Chait compliments Chu for her “honesty”—relative to the efforts of liberal advocacy institutions like GLAAD to fight on the same pathologized ground as Chait—he critiques her argument for lacking “empiricism:”

That belief grows out of bitter experience trans people have had with a medical profession that long pathologized them, extending their opposition to medical gatekeeping to children. The rights-based approach put it in conflict with medicine’s “do no harm” ethos, which tends to demand evidence for interventions…The youth gender status quo that activists have presented to the public as the clear consensus of experts in the field is, in reality, the product of a political struggle between practitioners who believe something like Chu’s case for sex-change-as-human-right against those who believe medical evidence calls for more caution.

Which, in the medical context, is true. There is an active and robust debate among healthcare researchers and professionals, including some leaders in the field like Dr. Marci Bowers and Dr. Erica Anderson who are themselves transgender, across Europe and North America about the level and kinds of assessment appropriate to ensure every patient receives the care that is right for them. Indeed, it would be strange if there weren’t—all fields of medicine are subject to a constant state of review and revision.

As someone who is largely in agreement with Chu (you’ll have to forgive trans people for being maximalists about our own self-determination) I’ve seen this medical debate about transgender medicine as braided alongside a long line of other debates between medical paternalism and patient autonomy. Indeed, most of the medical controversies you can likely name from the last century of medicine have (as scholars no less esteemed than Dorothy Roberts and Barbara Ehrenreich have emphasized for decades) stemmed from a lack of patient autonomy rather than an excess of it. Forced sterilizations, lobotomies, conversion therapy, even thalidomide were tools in the hands of a medical establishment that declared itself the final arbiter of “empirical” health on behalf of a racist, capitalist, and patriarchal order. Those contests continue well into the present day with mixed results—See the approval of the first over-the-counter birth control medication, the controversy over “applied behavioral therapy” for autistic kids, the use of bariatric surgery to treat obesity in adolescents, or the many, many, many scenes of discord in the ongoing COVID pandemic.

Much like transgender medicine, none of the above are removed from politics, morality, or ethics, and all are the focus of activists seeking to break down a litany of interconnected biases and harms that have long plagued medicine by making the same kind of moral and empirical arguments made by Chu. But transgender medicine is facing something none of the above are currently facing today, something that threatens to not only chill debate about this care but leave unanswered the many questions Chait and others claim to have while opening up new, deeply concerning ones. The biggest factor facing transgender medicine in the United States right now—the largest cause of chaos and threats to providers and patients alike—is not transgender people like myself or Chu nor advocacy groups like GLAAD. The largest and most uncertain change in the status quo of transgender medicine are the bans.

Remember the bans? The 23 statewide bans on gender-affirming medical care for transgender youth passed in just the last three years? The bans that are already working to deny over 100,000 transgender youth any access to this care at all? The bans that threaten to put doctors in jail, artificially hike their malpractice rates, and even chill providers who practice in states without bans? The bans opposed by medical providers like Bowers and Anderson that Chait and others love to cite to justify their skepticism? The bans that have been written and defended by the very same groups manufacturing doubt around mifepristone and birth control? The bans fueled by open corruption and pay-for-play junk science? The bans that would censor any mention of transgender medicine in federally-funded agencies and medical schools? The bans passed by politicians who describe trans people as “filth,” “demons,” and a “contagion” and predictably advocate for extending those bans to transgender people of any age? The bans racing towards a Supreme Court review? Those bans?

I ask because it’s not clear to me many liberal commentators like Chait actually do remember. He makes zero mention of them in his response to Chu other than a quick note that “conservatives dismiss trans rights altogether.” In the more than 6000 words he’s written about transgender youth in the last year, just 119 (or 2%) gesture towards the bans and none explore the many harms we know they’re already causing. Elsewhere, you find liberal pundits and reporters alike casting the bans as simply the mirror image of trans people fighting for greater access. See Pamela Paul (who conflates politicians using the power of the state to target providers with amorphous and unnamed “activist pressure and organizational capture”), Emily Bazelon, (which likewise goes to great lengths to characterize bans and “activists” as two equal extremes), and the New York Times heavily-criticized fear-mongering about puberty blockers (which makes brief reference to the bans before equating them to “some advocates [who] criticize anyone who questions the treatments’ safety.”)

This makes for a dangerous game of whataboutism, one that risks gravely misrepresenting both the facts and the unknowns about the state of this health care and the power imbalance at hand between transgender people and the political movement dedicated to our eradication. It’s a rhetorical maneuver that conflates a medical debate between “more assessment” and “more autonomy”—the kind of debate that unfolds in medicine all the time across a wide range of topics without this level of political and media panic—with a political debate between “transgender rights are human rights” and “transgender people are an abomination unto God.”

Whether engaged through ignorance or malice, the refusal to amplify the risks of the bans on medical care and instead dedicate nearly all focus on the (manageable and rare) risks of the medical care itself is a failure to respond to both the moral and the empirical harms facing tens of thousands of transgender youth and their families. It is a method of retreat for liberals like Chait away from the very liberal values they claim undergird their entire worldview in defense of rigid and shallow conceptions of liberal identity. After all, if we take Chait at his word and believe his concern is about “empiricism,” then a dangerous and radical new front is needlessly being created for openly-bigoted reasons under his very nose.

Compared to the decades of research conducted into the benefits of gender-affirming medical treatments for transgender youth, what’s now unfolding in states that have banned access is fraught and untested water. As Dr. Kellan Baker of the DC-based Whitman-Walker Institute, told Slate:

What’s actually happening is a really cruel science experiment, where trans kids who are happy and healthy—under the care of their doctors, with the support of their parents—are now being forcibly taken off their medication, which is absolutely medically contraindicated. And we know it’s going to hurt them. And so the effect of this experiment seems to be: Just how badly will we hurt them?

Six states require doctors to gradually remove their patients from health care in a manner that is “safe and medically appropriate.” The problem with that, as doctors have made clear, is that it’s literally impossible:

“There’s no appropriate way to do that because it’s medically necessary treatment,” said Alex Keuroghlian, an associate professor of psychiatry at Harvard Medical School and the director of education and training programs at The Fenway Institute, which focuses on LGBTQ health research and policy. “The premise is flawed.”

“You can harm someone at whatever pace you want, but you’re still harming them,” Keuroghlian said.

As one Yale University researcher put it, “It feels like they’re asking us to experiment on our patients, which is funny because that’s the very thing they’re accusing us of.“

The bans being either completely ignored or conflated with transgender people’s own advocacy as patients by liberal commentators are thus creating exactly the kind of vacuum of knowledge and evidence those very same commentators claim to be concerned about. Seemingly demanding absolute certainty this care provides zero risks (an impossible standard for any field of medicine to reach) they simultaneously ignore or sweep aside the undeniable fact the vast majority of the transgender youth being pulled off this care by state politicians right now have built their lives on this care and will now be forced to endure needless distress and suffering without this care.

That distress and suffering will come not from just being denied their self-determination over their own body—though that is already a moral injury proponents for these bans have failed to justify. It will also come from the permanent physical effects that these youth will be forced to endure without puberty blockers or hormone treatments. Indeed, while Chait and others frequently express concern for the (small number of) patients who access hormones from a doctor that change their bodies in ways they later come to regret, they don’t seem to have the same concern for the (large number of) people who are denied hormone blockers from a doctor likewise resulting in changes to their bodies they know they will regret. “If children are too young to consent to puberty blockers,” writes Chu in her essay, “then they are definitely too young to consent to puberty, which is a drastic biological upheaval in its own right. Yet we let this happen every day — and not without casualties.”

Or, as Lydia Polgreen put it, “a single mistaken transition is a tragedy. A million children denied care? That’s just a statistic.”

This is why it’s impossible to consistently express concern for transition regret without expressing concern for regretting a lack of a transition: both outcomes are functionally the same. While everything we know about this care suggests the latter is much, much more common, these are not competing interests—both are seeking the same relief. So to fret about the former and ignore the latter is to scream about possible suffering while ignoring certain suffering, to dread the risk of making the wrong choice while politicians use the power of the state to deny us any choice.

@luckartikasariReplying to @Courtney Burum also the diagnostic period was LONG. so many appointments 😪 #detranstok #detransitioning #detransgender #queertok #queer #detrans #dutchqueer

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So while liberal commentators portrays themselves as simply evidence-based technocrats attempting to stake out a middle ground between trans people seeking to maintain our autonomy and politicians using the state to deny us that autonomy, they clearly are making a moral choice to spend their time and influence telling their readers trans people are a threat and anti-trans politicians an afterthought. It’s an act of malpractice akin to letting arsonists burn down a house full of children because you’re too busy warning the tenants to change their air conditioner filter.

How do we explain this selective retreat? In perhaps Chu’s most poignant paragraph, she writes:

The freedom of sex does not promise happiness. Nor should it. It is good and right for advocates to fight back against the liberal fixation on the health risks of sex-changing care or the looming possibility of detransition. But it is also true that where there is freedom, there will always be regret. In fact, there cannot be regret without freedom. Regret is freedom projected into the past. So it is one thing to regret the outcome of a decision, but it is a very different thing to regret the freedom to decide, which most people would not trade for the world.

Whether Chu intends it or not, this is a very liberal sentiment. Not liberal in the sense of wishy-washy centrist or to the right of the left—a cynical and amoral act of political positioning. But liberal in the sense any restriction on self-determination should meet a high bar, one the bans on gender-affirming medical care simply fail to clear. This central value—shared by classical liberals and social democrats alike—is being sacrificed by self-describe liberals paradoxically in the name of the liberal order, pitting their vision of freedom against their essentialist faith in identity.

Consider Isaiah Berlin, who would describe the “freedom to decide” as having both a negative and positive conception. In the negative conception, said Berlin in his famous 1958 lecture, freedom is simply defined by a lack of coercion whether by the state or economic deprivation. Actions by others interfere with this freedom by “directly. or indirectly, with or without the intention of doing so, in frustrating my wishes. By being free in this sense I mean not being interfered with by others. The wider the area of non-interference the wider my freedom.”

If the negative conception is “freedom from,” then the positive conception is “freedom to”—freedom from coercion versus freedom to self-determination. “I wish, above all, to be conscious of myself as a thinking, willing, active being,” writes Berlin, “bearing responsibility for my choices and able to explain them by references to my own ideas and purposes. I feel free to the degree that I believe this to be true, and enslaved to the degree that I am made to realize that it is not.” But as Berlin also notes, no man is an island—we are raised in society that invests in us passions, goals, fears, and anxieties that determine how we might choose to use that “freedom to.”

By any measure, transgender people are denied both conceptions frequently and routinely. We are denied access to medical transitions by widespread poverty, open bigotry in the medical field, discriminatory insurance exclusions, and now political efforts to weaponize the power of the state against us. Even if you claim some limitations on care are necessary for youth, it doesn’t explain why trans youth only are denied access to the very same treatments afforded to cisgender youth—including surgery—to affirm their gender assignment rather than transgress it.

But we are also denied Berlin’s positive conception of freedom, raised in a sociocultural context that regards any life outside a rigid-yet-fragile binary as errant and doomed to fail. Trans people who started challenging our gender assignment as children before the very notion of a transgender child had entered mainstream discourse were denied any vision of a life outside our assignment, and the finality and certainty of that assignment continues to be a powerfully-immersive hegemonic force shaping the will of young people today.

For someone who doesn’t perceive that force—who is like the fish asking “what’s water”, the creationist marveling at the intelligent design of the banana, or the puddle convinced the hole they find themselves in was crafted to their exact specifications—it is the very notion trans people exist that is perceived as an external force, a ideological pollutant obscuring what Berlin calls “an occult entity - their latent rational will, or their 'true' purpose - and that this entity, although it is belied by all that they overtly feel and do and say, is their 'real' self, of which the poor ‘empirical'self in space and time may know nothing or little.”

This is the kind of (intentional or not) misdirection Berlin notes allows for the oppression of others to take a paternalistic, benevolant form. Those doing so take the position that:

“…this inner spirit is the only self that deserves to have its wishes taken into account. Once I take this view, I am in a position to ignore the actual wishes of men or societies, to bully, oppress, torture them in the name, and on behalf, of their 'real' selves in the secure knowledge that whatever is the true goal of man (happiness, performance of duty, wisdom, a just society, self-fulfillment) must be identical with his freedom - the free choice of his 'true', albeit often submerged and inarticulate self.”

To either the right-wing politician or the liberal pundit, the very prospect of regret is proof some “true self” lies buried under every trans person’s desire to change their sex, one that seeks to conform to an innate gender assignment rather than transgress it. What Chait and others perceive as trans activists’ efforts to shut down debate are more often efforts to point out how the contours of that debate are shaped by this core fallacy, one transgender people ourselves are in a unique position to identify. It is a “debate” where the priority is the defense of liberal conceptions of identity as essentialist and innate at the expense of liberal conceptions of freedom and self-determination. It is, in fact, a mirror (in affect if not in the scale of oppression) to the contradiction Berlin himself engaged in through his paternalistic justification of Zionism.

Transgender medicine today is not, as its frequently portrayed, a Fordist factory line for either youth or adults. It has evolved well past the paternalistic and abhorrent mission of its earliest practitioners to transform queer, deviant men and women into heterosexual, gender-conforming women and men—a last resort after the failure of violent conversion therapy. Thanks to the transgender advocates Chait and others portray as our own worst enemies, that eugenicist project has been gradually (and incompletely) replaced with an individualized form of medicine which, at its best, is built on patient autonomy, informed consent, and trust between patient and doctor that honors both the risks that come with subjectivity and that subjectivity itself.

This has resulted not only in more people accessing care but mirrors transformations that have granted more autonomy (in most contexts) as it applies to contraception, abortion, and other medical technologies that help us navigate our gendered and reproductive lives. And as with abortion and contraception, the gravest threat to transgender medicine is an active political movement dedicated to erasing not only the availability of this care—for youth or adults—but the very liberal values its loudest skeptics claim to hold dear. If they continue to join that movement in fear-mongering about trans people and our health care, losing those values is far more than a risk.

[Note: There’s a lot I have to say on liberal transphobia that I didn’t get into here, from what I mean about “essentialist” identity to its relationship to the construction of race, class, and disability to the role of the medical state in that project. Subscribe for free and I’ll surely write about those in the future]