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All Trans Kids Deserve Care: A Response To Helen Lewis

Helen Lewis, noted anti-trans author, wrote for the Atlantic on the “child gender culture war,” saying that not all trans children should be given access to gender-affirming care. She is wrong.

Charlotte White

May 19, 2023
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Photo: Helen Lewis on Channel 4 News

On May 4, the Atlantic published an article by noted anti-trans author Helen Lewis, titled “The Only Way Out of the Child-Gender Culture War.” Therein, the author asserts that gender-affirming care is unnecessary for the mental health of young people experiencing dysphoria. She implies that there are some trans people who really are trans and deserve access to care, but that an even larger number of people are only claiming to be trans, but aren’t, and they must be prevented from accessing gender-affirming care.

As is so often the case when major publications run transphobic articles, the language and framing of this piece presents its rampant transphobia in a subtle way, so that the author can still claim that they’re only trying to engage in “good-faith debate” — in fact, Lewis makes that exact claim, word for word. But far from having a “good-faith debate,” this article implies that gender-affirming care is unnecessary, that gender is something that exists internally and has no external, material component, and that the realization of transness is simple and obvious, rather than a nuanced and winding path. To combat the current attack on trans people, particularly trans youth, it is vital for the Left to engage critically with this transphobic rhetoric. In this battle, we must study and understand the enemy.

Gender-Affirming Care Is Mental Health Care

Lewis is concerned that the uptick of gender-affirming care results from alarmism and the supposedly “false” claim that gender-affirming care is necessary for trans people’s mental health. She writes that “left-leaning activist groups and the White House regularly describe child transition as ‘lifesaving’ and raise the specter of suicide if care is withdrawn.”

First of all, Lewis ought to include sources for when the White House took trans children’s mental health so seriously that it expressed concern about the suicide rate of trans individuals, which remains much higher than that of their cisgender peers, because we certainly have yet to see the White House take the firm stance that Lewis attributes to it. Second, it is irresponsible and dangerous to call the suicide rates of trans children a “specter.” When using this term in this context, Lewis is subtly implying two things: That this “specter” may be entirely or largely imagined, and that the “specter” is being dramatized for the purpose of inspiring fear, thus accusing the Left (and apparently the White House) of using the trans suicide rate as a bogeyman. But the mental health of trans youth is not to be ignored, and trans youth’s high rate of suicidal ideation, suicide attempts, and suicide are not a minor detail.

Research has found that a staggering 82 percent of trans individuals have considered suicide, and 40 percent of trans people have attempted suicide. The highest rate of suicidality is among trans youth. Clearly, this “specter” of trans youth suicide is not imagined, nor is it being dramatized. Furthermore, research has also shown that receiving gender-affirming care lowers depression and suicidality among trans youth. One study found that trans youth receiving gender-affirming care had 73 percent lower odds of suicidality and 60 percent lower odds of depression.

Trans children experience aggression, bullying, and invalidation on top of gender dysphoria every day, and the damage this does to their mental health ought not be written off. The two greatest contributors to more positive mental health outcomes for trans youth are support from family and friends, and access to gender-affirming care. It is no overstatement to say that children die without these resources. Thus, if fear is rising due to the restriction of gender-affirming care for minors across the nation, the risks this fear is based on are not imagined, nor are they being dramatized by the Left. It is rooted in the material reality that trans youth are much more depressed and suicidal than their cisgender peers, and that a major antidote to this startling rate of depression and suicidal ideation is being banned. This is not an abstract, dramatized specter. This is reality.

Gender, Materialism, and the Limits of Talk Therapy

To dodge accusations of transphobia, Lewis does offer some “solutions” for trans youth, so as not to simply leave them to suffer. Namely, Lewis places extensive value in talk therapy. She writes,

Every child experiencing distress deserves supportive treatment, which can take a variety of forms. … But from the statements of leading practitioners, we do know that many have rejected a model called “watchful waiting,” where extensive talk therapy is preferred to puberty blockers, cross-sex hormones, and surgery — or at least seen as a prerequisite for those medical interventions. Instead they favor “affirmative care,” which is grounded in the belief that “kids know who they are.”

Here we see Lewis leaning in to the common idea that gender-affirming care is unnecessary, and that what kids really need is extensive talk therapy to figure out who they are and learn to love themselves. This falls flat for two reasons: First, talk therapy has serious limitations. Second, gender identity is not simply an immaterial feeling that only exists internally, so it cannot simply be talked about until a person “feels better.”

While talk therapy can help and should absolutely be made available and accessible to all who would like it, including children, there are limitations to the benefits of talk therapy, namely the impact of one’s material conditions. As psychologist Dr. David Russel writes,

Sometimes changing the way you think isn’t a permanent solution to your problem. … Talk therapy often works well in reducing and controlling your emotions. But anything that triggers stress hormones … can cause a full relapse, the immediate and full return of your symptoms.

What this reveals is vital: talk therapy can help us navigate our response to our material conditions, but it cannot change the material conditions themselves, and thus cannot eliminate these stressors. In this case, no matter how often or how thoroughly trans children are talking through their gender-related feelings and stresses, talk therapy alone cannot get at the heart of the issue. These children are experiencing gender dysphoria, and the best way to address this material stressor is to provide them access to tools that relieve this dysphoria: complete and total support and gender-affirming care. Talk therapy can help trans people navigate the complexities of social transition (changing names and pronouns, expressing themselves in a more masculine or feminine way, etc.), but it cannot provide the vital change in material conditions that access to gender-affirming healthcare can give trans people. Whether or not a person chooses to use medical intervention in their transition (one is still trans even if they choose not to), it is vital that children be allowed the option to take this route and that caregivers encourage open, honest conversation about this option so that children can gain a better understanding of themselves as trans.

Gender (and the experience of being transgender) is oftentimes thought of as a purely internal process, wherein a person self-reflects on their inner workings and finds out who they are “on the inside.” The description of transness as being a “girl on the outside but a boy on the inside,” for example, is oftentimes as far as cisgender people go when considering what it is to be trans, whether they are anti-trans or trans-supportive. The reality, however, is that gender is two-pronged: it includes both gender identity and gender expression. These two ideas are distinct but intertwined, and one cannot fully explore their trans identity if they are being restricted from doing so in both areas. Of course, one can still be trans, even if they are not able to explore both prongs of transness, but their trans identity remains bound-in. If a young trans girl, for example, cannot safely go by a new name, wear makeup or feminine clothing, or start using she/her pronouns, she is still a girl in her gender identity, but her gender expression has been halted, which is extremely limiting and will likely produce more acute mental health symptoms arising from the contradiction between her identity and expression. Beyond this, if a person is halted from changing their gender expression, it is extremely unlikely that they will be gendered correctly in any setting, and therefore every interaction they have will remind them that their outer expression stands in distressing contrast to their inner identity. This constant misgendering has a terrible impact on a young person’s self-esteem and quality of life; this is deeply important and cannot be written off.

To assert that trans children do not need access to gender-affirming care and should rather focus on talk therapy alone is to deprive these children of the full experience of their trans identity. Gender identity and gender expression go hand in hand, they inform one another, and they often grow and develop in tandem. Trans people understand their trans identity more fully when they are allowed to expand and shift their gender expression, and part of this exploration is the option to use medical intervention in their gender transition, whether or not they actually decide to use it. Cutting off children’s access to resources that help them find their gender expression and focusing only on gender identity is an undialectical and immaterial approach to transgender care, and it cannot be peddled as a real solution to a trans child’s dysphoria.

The Myth of “Extenuating Circumstances”

Perhaps the most prominent argument arising in anti-trans circles today is the idea that some people really are transgender and deserve access to gender-affirming care, but that most those who identify as transgender are not part of this allegedly minuscule group of folks who are really transgender, and are apparently only identifying with transness because of this “culture war” being peddled by the Left. This this “gender skepticism” is quickly becoming dominant anti-trans rhetoric, appearing in the New York Times and the prominent anti-trans book Irreversible Damage: The Transgender Craze Seducing Our Daughters.

Lewis, too, pushes this ideology: she opposes banning gender-affirming care, but believes that heavy restrictions ought to be placed on its access, so that those who are simply confused can have time to talk through this confusion without gaining access to gender-affirming care. She goes on to say that there are certain extenuating circumstances wherein a minor should be allowed to access medical intervention for dysphoria relief. She writes of a child whose first expression of transness was at age four, asking her mother, “Why did you make me a boy? I wanted to be a girl.”

Lewis uses this anecdote as an example of a child who is truly transgender, evidenced her having these feelings at a very young age and being able to name them clearly. But the truth of transness is that the vast majority of transgender people do not have one singular moment when they suddenly realize and with clarity that they are, for example, a boy when they wanted to be a girl. A more accurate picture of trans identity is one of fits and starts: twinges of discomfort in one’s gender presentation, denial of the discomfort, eventual acceptance of this discomfort as dysphoria, experimentation with gender, circling back to denial, and much more winding along the path, oftentimes for years. The vast oversimplification of trans identity that Lewis (and others) puts forward implies that transness is something unchanging and internal — a hidden treasure to be discovered, rather than a complex and shifting identity to be understood, expanded, and built.

The consequence of this oversimplification is twofold: on the one hand, it completely invalidates the experiences of trans people who take a long and winding path to understanding their gender, and it implies that they are not actually trans, but rather confused and swayed by social pressure. On the other hand, this oversimplification largely erases the identities of nonbinary and gender-nonconforming trans people. The simplistic idea of transness that Lewis adheres to is incredibly binary: the only “real” trans people she speaks of are those who realize that they are a “girl in a boy’s body,” for example, and she makes no room for those who do not fit neatly into “girl” and “boy” categories.

Anyone who does not identify with their gender assigned at birth is transgender — they need not be a trans man or trans woman. Trans people who exist outside the category of man or woman also need access to gender-affirming care. Nonbinary and gender-nonconforming people commonly seek hormone replacement therapy, surgical intervention, and puberty-blocking medication to relieve dysphoria. If we hold that only those who experience Lewis’s “extenuating circumstances” — those who experience extreme, early-onset, binary, and clearly expressed gender dysphoria — ought to have access to gender-affirming care, we eliminate the enormous majority of nonbinary and gender-nonconforming trans people from accessing these things, as well as huge swaths of trans men and women.

The Consequences of “Just Asking Questions”

It is clear, then, that Lewis and her “gender-skeptical” counterparts are not actually interested in protecting gender-affirming care for those who “truly” need it and “protecting” others who are not actually transgender. This argument, and Lewis’s article, are anti-trans talking points disguised as concern. This tendency to thinly veil anti-trans rhetoric under the guise of “asking questions” and “allowing for concern” does nothing positive for the trans community, and instead opens up space in moderate and liberal spaces for transphobia to sneak in.

By oversimplifying trans identity, ignoring the material aspects of gender, and pushing inadequate “solutions” to gender dysphoria, Lewis and her gender-skeptical peers have created a scenario wherein the transphobic attacks are not exclusively coming from the  Far Right. Yes, it is important to understand that extremist right-wing politicians are behind the onslaught of anti-trans legislation in the United States, but the role of this “gender-skeptical” rhetoric, wherein transphobia is brushed off as “just asking questions,” is also extremely dangerous.

When major publications and publishing houses sell articles and books pushing this “skeptical” ideology, space is made for not only right-leaning people, but also center- and left-leaning folks to hold anti-trans ideology unchecked. This leads moderate or liberal folks to take no stance against anti-trans attacks, and it leads the parents of trans children to prevent them from accessing gender-affirming care while shielding themselves from accusations of transphobia. Articles like Lewis’s give space for parents to “just ask questions” while withholding vital medical care from their kids.

On the Left, we must not allow this to continue. Gender skepticism holds no place on the Left, and we cannot allow for it to emerge on the Left the way it is emerging in center and liberal spaces. It is vital that our demands remain unflinching: free and accessible gender-affirming care for all who want it, including youth. No concessions can be given to transphobic writers like Lewis, no matter how thoroughly she has tried to defang the cruelty of her sentiments. It is not alarmist to point out that trans children are under severe attack and that their lives are absolutely at stake. In a battle this serious, we must make no compromises.

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Charlotte White

Charlotte is a teacher and childcare worker in New York City.

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