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 2024-2025Knight Science Journalism fellowship class at MIT.
"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."
Whoa. I am a long-time reader and fan of your writing, and am really grateful for the work you do, but you totally lost me here. I think you are mistakenly allowing yourself to generalize on the basis of your own very particular experience of your transness.
I also approached transition with an attention to the empirical evidence, consulted with endocrinologists, read journal articles, etc. But the process of deciding whether to take hormones was, for me, the process of deciding whether I wanted to change my body in the way that hormones would allow. It wasn’t anything like looking down at my bad knee and being like, "Which treatment will alleviate this pain and make my body whole?" It was more like deciding whether to get married or have children – "What do I really want in life?" ‘Vocation’ is a word I would readily use. I did sit with it for a while and do my research and really think about it, and that seems to me good and responsible. But we do not require that people do this before having children or marrying someone (even if the choice could be a wrong and harmful one, and even if it would be the responsible one). Ultimately I was able to show up at a doctor’s office and ask for hormones because I wanted them, and that was it. That’s how it should be – that is what we need to fight for. The vision should be one in which transition is just one of many beautiful and transformative things one might choose to do with one’s life, as part of the lifelong and universal process of negotiating between inner desires and living among others in society.
And fwiw most of the trans people I know would probably assent to some version of this. I suspect there’s a generational divide here, and that increasingly many young trans people think of their transness as a vocation and a life path rather than as a palliative.
(Re-submitting (?) bc I think I clicked away before hitting post)
I wouldn’t take a pill that makes me cis. It wouldn’t be me anymore. If I wasn’t a woman that would be even more disruptive to my identity than transition. I was to be a girl and being cis is giving up on that and I think think I could ever really feel comfortable as a man even if some pill supposedly got rid of my dysphoria
I’ve appreciated your work for a long time, but I honestly think you’re off-base here. I don’t think the ‘panic’ you’re attributing to Chu is really there in the text – she’s not worried about the evidence; she’s indifferent to it – and it seems that you’re allowing yourself to over-generalise from your own particular experience. What you assert about the hypothetical cis pill ("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") seems to have no evidentiary basis outside of yourself, and directly contradicts the majority of what I’ve seen trans people write about that hypothetical.
https://twitter.com/spargles/status/1628228876236390401?t=LX2zXfgjMz3SkoaigedSKg&s=19
^ As an example, here is a 2023 tweet (from a cis person) musing about exactly that: a pill that could make trans people cis. I’d suggest disregarding the actual numbers in the poll – one can assume a lot of cis people voted – and instead focus on what trans people actually wrote n the replies and quote-tweets. The response to this hypothetical was largely one of repulsion. People compared the prospect to a lobotomy, to brainwashing, to being killed and replaced by someone different. Some trans people did comment that the hardships of being trans are bad enough that they would take the pill, but they (and you) seemed to be in a minority on this.
Now, if the pill worked in a different (and more magical) way – if it made the trans person cis as the gender they want to be – then I suspect you’d see vastly more take-up. But even then, I don’t think you’d get universal take-up from trans people. For many of us, the experiences of transitioning are simply too inextricable from our personhood to imagine it ‘cured’ without that cure having the feel of a dehumanising soul-lobotomy.
The responses to that Spargles tweet obviously aren’t equivalent to a good big quantitative survey, but they might be enough to convince you that you might be missing something here about the broader trans public.
(P.S. I wrote about the Spargles tweet once before, in a blog post I wrote when I had just recently started hormones. My experience obviously isn’t universal either, but for what it’s worth: I had to consciously detach from the medical model of dysphoria-alleviation in order to allow myself to try hormones, which ended up being the manifestly right decision. A world in which transition healthcare is available as a right for anyone who wants it includes everyone who can currently be assessed as having gender dysphoria, but a world of medical gatekeeping would specifically exclude trans people like me. Without informed consent, I’d be nowhere:
https://becausegoodbye.tumblr.com/post/710832000381173760/moving-into-a-more-transfeminine-space-an )
I appreciate this comment.
I support the informed consent model of care. My support is informed by the medical evidence that gatekeeping does not improve outcomes. It’s a misreading of this essay to think it supports gatekeeping over informed consent.
It is true that if there were evidence that longer assessments led to higher satisfaction and better quality of life, I’d support them. There isn’t. I think the length/type of assessments done before patients can access treatment ought to be based on what helps patients most.
The most controversial line of the article is this idea that I suspect most trans people would take a pill to cure their dysphoria rather than undergoing a transition. I don’t think it’s possible to know, I think it was a poor articulation of the point I was trying to make (that like anyone else trans people want healthcare that helps them, not harms). I also didn’t clearly say that I think such a pill would be impossible, though I do. However, my hunch was informed by my belief that more people are still closeted and living as if they were members of their birth sex than are out as trans. I think it’s really unknowable, but if you understand I think there are a lot of trans people who are not transitioning and managing the pain of dysphoria alone and without help, it may make more sense where that guess came from.
Thanks for the comment, love to see the discussion.
I’d like to reiterate what Audrey says below, I so appreciate the work you do and your well-researched and erased writing, but I too feel there is a lot to push back on here.
When I read Andrea Long Chu’s piece, I too had some apprehension about some of her bolder statements. But it was more from the perspective that she was going places the mainstream culture is not ready for, but they are places we probably need to go. To me she was writing more from a t for t perspective. In the same way that author Torrey Peters can take back the term "detransition" in her book Detransition Baby and open up a trans perspective to a larger audience. While provocative at this point in time, the gambit is this will help society evolve and come to new understanding of gender and identity. Chu seems to be working more from a Neo-Marxist perspective, not a libertarian one. We DO need to free ourselves from the medical-industrial complex – but, fully realizing that is impossibe at this time, – we do NEED the medical industrial complex. The points Chu makes are legitimate and real and part of a conversation that is ongoing in trans literature and academia, see Paul Preciado, Testo-Junkie, Can the Monster Speak, etc. The place I think the piece above really gives me pause, is the idea that trans people do not want to be trans. I am not going to interject my own experience here, because I think that is the weakest part of the arguement above – we are all living our transness, and how you arrive at it is legitimate. What I will say, however, is that the better-to make-transness-just-go away-if-we-could argument reminds me of similar postures and conflicts within in the Deaf community, the Autistic community, etc. In each of these communities there is a strength of culture and identity that strongly pushes back against erasure. This is based on an understanding of the experiential differences these folx bring to the world as a positive part of a tapestry of human diversity, resulting in significant pushback against the idea that we should automatically default to trying to "cure" sensoral and neuro-divergencies. Likewise gender-divergencies. I think Evan would do well to be more questioning of the mindset that science is the unequivocal baseline for understanding transness. As we can see in the Cass report, and other "science", politics are inescapable. Chu is brave and forthright, though perhaps overly ambitious in her choice of venue – to propose a politics of transition based on rights owed, not disease diagnosed.
Great response, I have long been bothered by Chu’s writing and I think you hit it right on the head what my issues with it are.
As always, you self appointed “realists” are the most hopelessly mired in fantasy. Obviously all mainstream institutions are aligned with your fantasy so you’ll never need to see it as such. Maybe one day read some phenomenology and you’ll understand that philosophy isn’t just about academic abstractions