There Is No Reason to Deny Trans People Necessary Medical Care

It comes as no surprise to us when we hear that many trans people suffer from depression even after full medical transition. But for some cisgender people, such as Richard A. Friedman writing for the New York Times, this fact can only be resolved by calling into question our very right to self-determine our genders.

It comes as no surprise to us when we hear that many trans people suffer from depression even after full medical transition. But for some cisgender people, such as Richard A. Friedman writing for the New York Times, this fact can only be resolved by calling into question our very right to self-determine our genders. Shutterstock

This has been a blood-red letter year for trans women. It’s been one of growing visibility blended, with terrifying seamlessness, into a rash of murders—18 in the United States, as of this writing—mostly targeting trans women of color and sex workers. Another case in the Philippines, meanwhile, saw American soldier Joseph Scott Pemberton murder a local sex worker, Jennifer Laude, claiming she had “defrauded” him and that he was defending his “honor.”

The terror created by these cases and others like them is real and should not be underestimated. Such heinous crimes are the tip of the abuse and discrimination that keep us balanced on the knife’s edge of liveability. It comes, therefore, as no surprise to us when we hear that many trans people suffer from depression or commit suicide even after full medical transition, up to and including reassignment surgery. But for some cisgender people, including those given national publishing platforms, this fact is a riddle that can only be resolved by calling into question our very right to self-determine our genders.

The New York Times published an editorial this week by Richard A. Friedman, professor of clinical psychology at Weill Cornell Medical College, who argued in part that the “best available scientific evidence” suggests we should not be believed when we talk about what we need or the truth of our genders—particularly, that there is no good evidence that medical interventions like sexual reassignment surgery actually improve our quality of life.

“Until we have better data, what’s wrong with a little skepticism?” he writes, leaving unspoken the fact that this means skepticism of trans people and what we assert about our own beings.

One of his key arguments relies on his use of a Swedish long-term study that can be misrepresented to argue that sexual reassignment surgery fails to ameliorate rates of suicide in transgender people, and that this further suggests that we are suffering from some deeper malady that cannot be cured merely by giving into our “cherished beliefs.”

“When the researchers controlled for baseline rates of depression and suicide, which are known to be higher in transsexuals, they still found elevated rates of depression and suicide after sex reassignment,” Friedman writes.

The problems with reading the study this way are myriad. Its control group was comprised of cisgender people, rather than, say, trans people who had not undergone reassignment surgery—a fact that even Friedman acknowledges. What this means, in effect, is that two vastly disparate groups of people with different social forces and external variables acting upon them, behave differently; hardly shocking. The lack of a proper control to minimize the possibility of unknown variables influencing the results renders the study’s scientific value somewhat dubious, at least if you’re trying to make an argument like Dr. Friedman’s.

Yet he still goes on to say, “On a broader level, the outcome studies suggest that gender reassignment doesn’t necessarily give everyone what they really want or make them happier.”

Further, the study itself contains the following caveat: “No inferences can be drawn as to the effectiveness of sex reassignment as a treatment for transsexualism.” The researchers freely admit that the condition of the trans subjects in their study might well have been worse without surgical intervention.

This issue is further compounded by the fact that other studies come to rather different conclusions. For instance, Murrad, et. al.’s exhaustive review of existing research—which Friedman mentions obliquely—argues that “sex reassignment that includes hormonal interventions in individuals with [gender identity disorder] likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.” But they also point out that many of these studies lack controls and call the evidence “low quality.”

Other studies have more conclusively demonstrated that the oft-criticised hormone treatments given to minors who experience gender dysphoria are not harmful and are easily reversible, and still another very recent study has done exactly what Friedman suggested and given us medical proof of the safety of trans hormone replacement therapy.

This is, of course, all rather preliminary; the surface has only just been scratched here. We have only recently begun to study transgender people properly, after all.

But Friedman’s analysis waves away anything that contradicts his argument and seems to pretend there is a nonexistent consensus in the limited scientific literature on us—even as he seems to claim more research is needed, he suggests we ignore that the vast majority of trans people, whatever our social problems, would never de-transition and instead argues we should be “skeptical” of trans people, particularly youths, who claim to need affirming health care. His is an argument for deadly inertia while he and his colleagues sort matters out.

Beyond the mishandling of this particular scientific analysis, Friedman’s piece reflects a wider obsession of cisgender people with this non-paradox of suicide and medical treatment.

It’s seen as a “gotcha” of sorts to act as an argument against granting us access to care we need. In general, cis people fixate on surgeries (witness how Friedman’s article opened with a lurid description of Caitlyn Jenner’s supposed reconstructive surgeries) and then seem to react with insatiable demands for explanation: Why would you do that to yourselves if it doesn’t stop you from committing suicide? From trans exclusionary radical feminists, to men’s rights activists, to evangelical conservatives, these arguments remain popular.

In short, Friedman and those who make similar arguments confound two separate maladies: the experience of bodily gender dysphoria and the morbidity caused by living as a second-class citizen. He announces, as if it were any great surprise, that addressing the former problem does not ameliorate the symptoms of the latter.

For instance, Friedman writes: “Given the absence of good treatment-outcome data, how can anyone—whether transgender activist, parent or clinician—be sure of the best course of action?” As I argued earlier, there is indeed a dearth of medical and psychiatric literature on trans people that addresses treatment. This is something we have protested for years, as it happens, because we do need that data. In a development that should surprise no one, we want to live happy and healthy lives, and prefer safe and effective medical treatments. That Friedman suggests the nebulous, nefarious trans community from which he fears “reprisal” wishes it to be otherwise is bizarre to say the least.

But we make the decisions we do to pursue health care because life is genuinely unlivable otherwise. My worst dysphoric years were characterised by crushing depression, suicidal ideation, failing and dropping out of college, lethargy, sleeping for 18 hours a night, and other abysses that I shudder to recall. Within a year of transition I was a straight-A student, rocketing back onto the Dean’s List, winning merit scholarships and appointments; now I’m a sociologist and write for a living as I work on my Ph.D. The usual sunny story, yes?

Sort of.

There are times when I still have thoughts of suicide, where depression, insecurity, and dysphoria all wrap around me again like a familiar old blanket. But it never occurs to me that my medical transition was the wrong course to take; I know the sources of my problems, and not all lie in gender dysphoria. Sometimes my bodily dysphoria has more in common with the insecurities foisted onto all women than anything specific to trans female experience, and my depression finds its roots in a thousand old furroughs, some of which include fear that I will not be accepted in society, or that my trans status will be used against me, or that I might be hurt for it. I’ve had a few close calls since I transitioned, after all.

But what is this if not a human life? Why do Friedman and so many other cisgender people assume that if trans-affirming healthcare does not solve all our outstanding problems, that it must be deficient and unneeded? As if we hold all treatment to that standard. And it is certainly bizarre to expect a psychological and biomedical treatment to fix a sociological problem—that is, the fear and anxiety created by being a member of a class subject to discrimination. Medical transition helped me take ownership of my body. Activism and political change is required to ameliorate the rest.

This is to say nothing of the fact that not all trans people want or need reassignment surgery—it is no longer as definitional of transsexual existence as it once was, and new generations of trans people are finding countless new and interesting ways of having a trans body. It’s a flowering deftly ignored by articles like Friedman’s, except inasmuch as he briefly uses the existence of such people to suggest that perhaps those of us who need surgery don’t. To truly respect trans existence would mean not trying to use our diversity to pit us against one another.

What afflicts us is not surgery but a world under the oceanic pressure of norms and prejudices.

Even leaving aside the more dramatic cases of trans women being murdered, we live in a world where we are seen as strange at best: something to stare at, something to passively exclude, some thing, rather than an equal person. Our bodies seem to exist as amusement parks for the fantastic curiosities of others. We are the conversation piece in cisgender society’s living room.

Ask yourself how that would make you feel, regardless of what medications you took or what surgeries you had.

Gender dysphoria as a whole—bodily and mental—is something imposed on us from without as much as something that manifests from within; it certainly finds its origins in deeply felt, physical sensations of wrongness, but it is also wildly exacerbated by the way trans people’s bodies are talked about, publicly possessed, and seen as inherently violable. In its subtle way, the Times editorial feeds that sense of objectifying entitlement.

This wider issue forms the foundations of all violence against us.

Men can often get away with doing absolutely anything to trans women in particular, especially if we do sex work: that double stigma is a brand that says “no one will miss you” in invisible ink all over our bodies. Even as men lust after us, they want to destroy us as an extraverted act of revenge against all womankind. Because they can.

They say we’re not “real women” and yet do to us the things they wish they could do to other women: their wives, their mothers, female politicians, the ball-busting boss, the ice queen who won’t date them. We are, in fact, the canvas of so many cisgender men’s own deeply unresolved psychological crises, which themselves never make it to the front page of the Times’ Sunday Review in the form of handwringing editorial piety.

You live with that knowledge and you learn to make peace with it, uneasy as it may be, and hope for the best.

Time and again, well-meaning cisgender people tell me and my sisters, brothers, and siblings, that we are so very “strong” and “courageous,” as if they intuitively sense how poisonous our world’s atmosphere is for us.

For my own part, I’m simply trying to fashion a liveable life, partially through these words, partially through the perambulations of my career, and in every case I find that the freshest air I breathe in this world is the result of work done, past and present, to help cisgender people see my existence as a way of being human.

But I needed medical transition in order to breathe in the first place.