In Defense of the Medical Model for Trans Healthcare
Andrea Long Chu thinks libertarianism will save the trans community. That’s bonkers.
Opinion, by Evan Urquhart
On March 11, Pulitzer-winning trans essayist Andrea Long Chu wrote a provocative essay for New York Magazine. Chu wrote against viewing transition through the lens of gender identity, dysphoria, and healthcare and offered the framework of a human right to change one’s sex as an alternative. Most controversially, she argued that this right ought to also extend to children.
A close reading of Chu’s essay, Freedom of Sex, finds that what she communicates most clearly is not a defense of freedom but deep fears about the medical establishment. Purporting to be a brassy attack on the sacred cows of liberalism, the essay does nothing so much as telegraph this terrified admission: Chu does not trust that the medical evidence will support giving trans youth access to gender-affirming treatments. As such, she’s deeply afraid of what might happen if transgender healthcare is allowed to stand or fall on the basis of medical evidence.
Throughout the essay Chu covers her fears up with belligerence. “The idea that trans people fundamentally suffer from a mental illness has long been used by psychiatrists to decide who “qualifies” for transition-related care and who does not,” she writes. “By insisting on the medical validity of the diagnosis, progressives have reduced the question of justice to a question of who has the appropriate disease.”
This undermining fear that gender-affirming care might not be an effective medical treatment was not lost on critics of the essay. The usual suspects treated Chu’s essay as a retreat, an admission that the evidence on gender-affirming care is weak and can’t be trusted. Jonathan Chait certainly took it that way in his response for NY Mag, and so did Helen Lewis for the Atlantic. Both writers homed in, correctly, on Chu’s great weakness: By arguing that there should be a right to change one’s sex regardless of whether it is beneficial or harmful to the person Chu is implicitly endorsing the idea that transition is, or could be, harmful.
This is not new territory for Chu. In a 2018 essay for the New York Times, she wrote that her gender-affirming surgery wouldn’t make her happy, and it shouldn’t have to. The NY Mag is basically a retread of those arguments, only with even less support for the idea that gender dysphoria is harmful and gender transition successfully relieves it. In 2018, Chu argued that a patient shouldn’t be barred from transitioning because a doctor has decided their distress isn’t severe enough to warrant treating it. By 2024, she’s not even going that far, seeming to have given up on the idea that relieving distress belongs anywhere in the argument.
It’s curious that these arguments purporting to present radical transgender opposition to milquetoast liberalism are appearing in these particular outlets, isn’t it? The New York Times and New York Magazine, home turf of Pamela Paul and Jonathan Chait, respectively? Why might these bastions of upper middle-class taste making feel comfortable publishing Chu, exactly?
The reason might be that Chu’s arguments all tacitly support the idea that restrictions on transgender healthcare would be reasonable for anyone who takes the liberal nanny state perspective. Chu argues stridently that this is not the perspective that should be taken, but if it is, welllll... The unstated implication here is that bans might be justified.
That’s certainly what Chait and Lewis argued in response, and can you really blame them? Chu left the door wide open, all those mediocre thinkers had to do was walk a straight line through it.
Chu, for her part, is not a mediocre thinker. However, she either hasn’t deeply engaged with the medical evidence, or doesn’t trust it. Not trusting medical evidence and medical authority while feeling, as all trans people do, that we must have access to transition, Chu wants to say that medical evidence isn’t really necessary.
While I’ve never won a Pulitzer, I have written about the science of transgender issues for about eight years now. My first science story, in 2016, was on the possible impacts of testosterone on language ability. (For reference, Jesse Singal’s controversial piece in the Atlantic about detransition came out two full years later.) When I tell you that the evidence in favor of gender-affirming care is strong, I believe I can do so from a place of some authority. The evidence is strong. Chu’s panic is unnecessary.
Trans people, including Chu, are correctly skeptical of medical authority. They fear doctors will abuse their power and arbitrarily restrict transition. They’re right, too: doctors will do so. Trans people also fear that anti-trans pressure groups will distort and confuse people about the quality of the evidence, and they’re right about that too: these groups have done so and will keep doing so. In the political battle to maintain access to our necessary and beneficial healthcare, trans people may lose for a season, even lose badly. That doesn’t mean there isn’t real medical evidence supporting us, or that the medical evidence shouldn’t matter.
I approached the question of transition from a very different perspective than Chu seems to have: I didn’t want to be transgender, but I was willing to transition if transition would be helpful to me. I approached the question of whether I should transition empirically, and I have continued to approach these questions that way ever since transitioning.
At times, of course, everyone desires things that they know will be harmful to them. We stay up late, we doomscroll, we watch bad television. We drink, even though alcohol is bad for us. Chu is right that freedom means the freedom to do things even if they might harm us.
However, when it comes to transgender healthcare, I’ve always believed that trans people, like other people, want their healthcare to actually help them. They (we) reject healthcare that hurts us. If the medical evidence suggested that a treatment other than transition would work better and be more beneficial, I think most trans people would ultimately wind up choosing it. This may be a disturbing idea to contemplate, it may read as an endorsement of conversion therapy, but my objection to conversion therapy is that forcing people not to be trans hurts them.* If trans people really could take a pill or have a few therapy sessions and become cis, like it or hate it, most of us would probably choose to do so. It might represent a loss to society of the unique perspectives and diversity trans people represent, but on an individual level it would make things so much easier.
Whether transition helps or harms transgender people is, ultimately, a question about our real world outcomes. Transgender healthcare either helps or doesn’t, and this can be established using real world evidence. In my eight years of covering this topic I have been convinced that the evidence strongly supports transition, and not only that but also supports reducing barriers, shortening assessments, and increasing access to transition for those who want it. However, science is a process of amassing more evidence and questioning assumptions. If the evidence shifted, so would my opinion.
Unlike Chu, I have no fear of this. Reality is reality, my job as a science writer is to learn about it and accept it. That doesn’t mean I’m unsympathetic to the idea that human freedom ought to include the freedom to choose things that harm us, but for a minority group that’s 1 percent of the population, I don’t hold out any great hope that libertarianism will protect us. By telegraphing her fears that the medical evidence might not support transition medicine, Chu gives succor to those who want to limit it even while seeming to offer an opposing viewpoint.
No wonder she’s one of the only trans writers being published in the New York Times and New York Magazine.
*UPDATE: An earlier version of this sentence read “This may be a disturbing idea to contemplate, it may read as an endorsement of conversion therapy, but my objection to conversion therapy is that it doesn’t work and forcing it on people hurts them.” It was corrected to clarify that the author’s objection is that conversion therapy hurts trans people, not that it is ineffective.
Evan Urquhart is the founder of Assigned Media and an incoming member of the 2024-2025 Knight Science Journalism fellowship class at MIT.