The Worst Argument for Youth Transition

The point of a public intellectual is to make wild arguments with maximum conviction. And in this respect, Andrea Long Chu—transgender woman, Pulitzer Prize–winning literary critic, irrepressible provocateur—always exceeds my expectations.

In a recent cover story for New York magazine, Chu makes the case for child gender transition using the most unpopular rationale possible: in essence, that minors should be allowed to have mastectomies and other gender surgeries if they want them, simply because they want them. “We will never be able to defend the rights of transgender kids until we understand them purely on their own terms: as full members of society who would like to change their sex,” Chu writes. “It does not matter where this desire comes from.”

Counterpoint: It does.

The most broadly appealing version of the argument for medical transition is that a small number of people have a psychological condition (gender dysphoria) that makes them unhappy (because their sexed bodies feel alien to them) and doctors have treatments (hormones and surgery) that can help.

In making the case for youth transition, activists have tended to emphasize the first part of that story—the distress of gender-nonconforming children—to justify treatments that would otherwise sound extreme. Even Marci Bowers, the president of the World Professional Association for Transgender Health, has noted that blocking puberty early means patients might never develop adult fertility or sexual function. The price of a genetically male child never growing an Adam’s apple or having his voice break—the outcomes that will help that child pass more easily as a woman one day—can be giving up orgasms and the ability to have biological children.

Put simply, this is not something that most parents would agree to—unless the alternative was worse. And so medical-transition advocates have highlighted the possibility of suicide by gender-nonconforming minors: Would you rather have a dead son or a living daughter? (Thankfully, adolescent suicides for any reason are rare, although rates have risen in the past decade.)

Treating gender dysphoria as a clinical diagnosis with a medical solution, Chu argues, has “hung trans rights on the thin peg of gender identity”—the idea of a male or female essence (or something in between) that resides inside all of us. She notes that this argument was copied from the marriage-equality fight, where activists stressed that being gay was an innate and unchangeable state, not a trend, a pathology, or something into which a person could be groomed or seduced. Adopting a similar “born this way” argument for medical transition, Chu writes, “won us modest gains at the level of social acceptance.”

[From the July/August 2018 issue: When children say they’re trans]

She doesn’t think this is enough. Instead, she makes an argument for full-throttle libertarianism, albeit without ever using the word. She doesn’t want grudging accommodations and delicately balanced rights. She wants people like her—born male and living as women—to have unfettered access to female sports and services, based purely on their self-identification. And she wants Americans of any age to have the right to “change sex,” a phrase she seems to define specifically in terms of medical body modification.

The stark facts of child transition are that when the puberty-blocker model was developed, a few hundred minors sought treatment every year—England’s main clinic had only 210 referrals in 2011—and those treated were mostly natal males who had suffered gender dysphoria since early childhood and exhibited no other mental-health issues. What kicked off the current debate was a steep rise in the number of children seeking care, and the changing demographics of those children. In recent years most of the patients have been genetically female, and many of them presented with other issues, such as autism, eating disorders, anxiety, or past trauma.

Undoubtedly, such children need parental support, counseling, and appropriate medical treatment. The “affirmative” model departed from this assertion, though, characterizing extensive psychological assessments as transphobic gatekeeping. Removing barriers to medical transition was a “life-saving” approach, supporters claimed.

However, the evidence that adolescent medical transition prevents suicide turns out to be thin. As early as 2018, the Gender Identity Development Service—Britain’s leading child gender clinic, staffed by doctors involved with transition-related care—criticized a television drama called Butterfly that showed a gender-nonconforming 11-year-old attempting suicide. “It is not helpful to suggest that suicidality is an inevitable part of this condition,” the clinic declared in a statement. “It would be very unusual for younger children referred to the service to make suicidal attempts.” Last month, a Finnish study concluded that suicide was rare among minors seeking help at gender clinics, and when deaths occurred, they reflected overall mental-health challenges rather than being specifically linked to gender dysphoria.

This emerging evidence doesn’t bother Chu, because she regards evidence as a real downer. She criticizes the writer Jesse Singal’s 2018 Atlantic cover story on child transition—which included interviews with doctors and patients who had a variety of perspectives on the issue—and claims that it ushered in an unwelcome phase of the transgender debate. “The story provided a template for the coverage that would follow it,” she writes. “First, it took what was threatening to become a social issue, hence a question of rights, and turned it back into a medical issue, hence a question of evidence; it then quietly suggested that since the evidence was debatable, so were the rights.”

[Daniela Valdes and Kinnon MacKinnon: Take detransitioners seriously]

For Chu, the primacy of rights means that evidence is irrelevant to medical decisions—even when children are involved. This view has two logical implications: The first is that, if we are now just letting kids do whatever they want with their bodies, why not let them get married at 12, or drink alcohol at 13, or consent to sex at 14 with an adult partner? “Toddlers have the right to get tattoos” might be the worst political slogan I have ever heard.

The alternative argument is that gender—however you define it—is so unique and important that it alone justifies total bodily autonomy for minors.

Whenever I read Chu’s work, I get the sense that she’s mocking the strand of feminism for which I have argued all my adult life. The project of feminism, from Mary Wollstonecraft onwards, has been to decouple the material reality of being born female from notions of passivity and femininity. But in her book, Females, Chu writes enthusiastically about “sissy porn,” in which “getting fucked makes you female because fucked is what a female is.” (Call me old-fashioned, but I prefer the more standard definition of XX chromosomes and the body type evolved to produce large gametes.) Shorn of identifying information, the author of that quotation could be assumed to be an old-school misogynist rather than a darling of the progressive left.

But such trollishness is Chu’s preferred style when writing about gender. (Her literary criticism is more straightforward.) She has written that she transitioned to experience “benevolent chauvinism” and to wear hot pants, and argued that “my new vagina won’t make me happy, and it shouldn’t have to.” The modern trans movement has largely tidied away the suggestion that sexuality—and particularly, the sexual fetish known as autogynephilia, where men become aroused by the thought of themselves as women—has anything to do with transition. Yet Chu has steamrolled through that taboo too, wondering aloud whether sissy porn made her trans. Sometimes I think only her ideological opponents actually read her work. Certainly, liberals tend to get uncomfortable when you quote from it, because they know perfectly well that this is not the trans-rights narrative approved by GLAAD and the Human Rights Campaign. You have to argue against her with one hand tied behind your back, politely overlooking her actual, published statements, including her claim that the anus is “a kind of universal vagina through which femaleness can always be accessed.”

Anyway, it turns out that I wasn’t wrong to think Chu is mocking me—because she is, specifically, by name. Her New York article includes me on a list of supposed gender-critical “militants,” alongside Singal, Matthew Yglesias, Matt Taibbi, Andrew Sullivan, Meghan Daum, and Bari Weiss. “Many of these writers live in self-imposed exile on Substack, the newsletter platform, where they present themselves as brave survivors of cancellation by the woke elites,” she writes. Never mind that to most of America, my European center-left views make me a woke elite. My offense is to be “preoccupied with the ‘science denial’ of radical activists, who have put wokeness before rational standards of care.” Yes, I do think doctors should have a good evidence base before giving out drugs used for chemical castration. Guilty as charged!

Chu identifies my fellow militants as an insidious force against the affirmative gender-care model. The queer theorist Judith Butler believes that only fascists—and trans-exclusionary radical feminists, or TERFs, whom Butler sees as fascists in disguise—have questions about the new orthodoxy on gender. But Chu is willing to grant us membership in a third category. We are TARLs, or trans-agnostic reactionary liberals. (To my ears, this doesn’t sound as catchy as TERF, but then, I haven’t yet had the newer term screamed at me through a megaphone by a six-foot figure in a balaclava.) “The TARL’s primary concern, to hear him tell it, lies in protecting free speech and civil society from the illiberal forces of the woke left,” she writes. “On trans people themselves, the TARL claims to take no position other than to voice his general empathy for anyone suffering from psychological distress or civil-rights violations.” Again, guilty as charged.

The ostensible hook for Chu’s argument is a new book by Butler, and the essay begins with a review of it. My impression, however, is that Chu finds Butler’s prose dull (relatable) and their persona dour; she clearly prefers her own rhetorical fireworks and provocative poses to Butler’s pioneering work in the field of impenetrable subclauses.

Chu’s real motivation, surely, is a sense that her side is losing. In Europe, where the “Dutch protocol” of puberty blockers was developed in the 1990s, several countries are turning toward talk therapy as a first-line treatment instead. Just after Chu’s essay was published, England’s National Health Service announced that it would no longer routinely prescribe puberty blockers for dysphoria, saying that the evidence for their safety and effectiveness simply was not good enough. France, Sweden, Finland, Norway, and even the Netherlands have also pulled back—hardly a roster of countries that you’d describe as being to the right of the United States. Crucially, these decisions have been led by doctors, not politicians, unlike in the U.S., where the debate is extremely polarized and the most high-profile opponents of youth transition are Republican governors.

[Helen Lewis: The only way out of the child-gender culture war]

But even in America, the debate is shifting. Quite a bit of Chu’s essay is devoted to complaints about media organizations that have not sufficiently echoed the activist line—that puberty blockers are safe and reversible, and that the “science is settled.” The New York Times is deemed to have fallen into the hands of barbarians, or at least failed to stop them from storming the affirmative gates. (Its recent publication of more skeptical articles has led to staff revolts.) “The paper consistently refuses to treat transition-related care the way it would any other health-care matter … as an issue of access,” Chu laments, ignoring the fact that if rates of women seeking abortions, say, rose by thousands of percent in a decade, the Times probably would write about the phenomenon.

The loss of the Times as a reliable ally matters because the American model of youth transition is best described as consensus-based rather than evidence-based—which is to say, it rests on the agreement of credentialed experts rather than on the conclusions of highly rigorous studies. And when the clinical rationale for underage medical transition disappears, what is left is ideology. “The belief that we have a moral duty to accept reality just because it is real is, I think, a fine definition of nihilism,” Chu writes. She would prefer to make a radical claim for unfettered personal freedom, even for minors: “Let anyone change their sex. Let anyone change their gender. Let anyone change their sex again. Let trans girls play sports, regardless of their sex status. If they excel, this means only that some girls are better at sports than others.” (It doesn’t, of course—it means that male puberty and higher male testosterone levels confer significant sporting advantages, but that’s me being a reality-accepting nihilist again.)

Above all, Chu argues, we should treat children’s statements about their identity with unquestioned reverence: “To make ‘thoughtfulness’ a requirement of any universal right is to taper that right into an exclusive privilege. That trans kids’ access to care will in most cases be mediated by parents or legal guardians is an inescapable fact of the way our society regards children, rightly or not. For now, parents must learn to treat their kids as what they are: human beings capable of freedom.”

In making a case this way, Chu shows a titillating disdain for respectability politics—and will surely irritate many people who share her political goals. For skeptics of puberty blockers like me, who are used to arguing against people who claim that any overreach in gender medicine is not really happening, or that too few patients are involved to be worth caring, or that we should be writing about something more important instead—all the riotous flavors of denial and whataboutism—Chu’s case for unlimited agency for teenagers is refreshing. She said everything out loud, and her argument is logical, coherent, and forcefully delivered. You just won’t hear it made very often, because it’s about as popular as the case for letting 9-year-olds get nose jobs.