“Are you male or female at the airport?” asks the TSA agent.
“Excuse me?” I say.
“Are you male or female at the airport?”
“My driver’s license still says male,” I say.
“Thank you,” he says before using his blue rubber gloves to tenderly rub my chest.
“Thank you,” I say.
This TSA agent is a believer in gender self-identification. That what I am at the airport is a matter of what I declare myself to be at the airport. And if by the time the plane is in the air, I declare myself to be something else, well then that is what I become. Nobody can know my gender better than I do, because gender only describes one’s internal sense of self.
This doesn’t mean that gender is unimportant. Our society is organized around gender. The TSA agent asked the question because the answer mattered for what happened next. If I had declared myself female, it would have been inappropriate and unacceptable for him to screen me. A female TSA agent would instead have been given that responsibility. Though my gender is determined internally, the external world has a duty to respond to it appropriately.
Helen Joyce would take a different approach to TSA pat downs. Were she to don the blue button-up and golden badge, she would skip the “are you male or female at the airport” question. She doesn’t need to ask because she already knows. She sees my stature and how I move. She hears my voice. And despite my long hair and adorable blouse, she effortlessly codes me as male. It’s not that I don’t look good, but eons of evolutionary programming are difficult to defeat. “Good afternoon. One moment please,” she would say, before going to fetch a male screener.
***
The central idea of Joyce’s Trans, When Ideology Meets Reality concerns the doctrine of gender self-identification. The idea that people should count as men or women according to how they feel and what they declare. Joyce argues that this idea is wrong. She encourages us to understand the movie The Matrix as an extended allegory for the doctrine of gender identity. (After the film’s release, sibling directors Lana and Lily Wachowski both transitioned from male to female.)
Most people in The Matrix experience a reality like our own. Yet, a small number know something. They aren’t sure exactly how they know it, but they can tell something is wrong. They find others like themselves, and eventually discover that they are trapped in a prison for their minds. By taking a pill, they can escape this false reality, and finally understand who they really are.
Just like the characters couldn’t perceive their true self within the confines of The Matrix, one cannot know their true gender through observation of the material world. The most salient aspects of gender can only be understood through introspection. We know gender identity exists for similar reasons that we know consciousness exists. Namely, that we feel it within our minds, or at least many people do. If you don’t personally experience a gender identity, it does not mean you don’t have one. Often, it is only when our gender identities clash with our external physical and social existences that they enter the foreground of our minds.
***
Joyce is skeptical of this story. When we identify with a particular gender, what exactly are we identifying with? Are we identifying with specific body parts or specific cultural rituals? If so, why shouldn’t these physical and social phenomena be viewed as the basis of sex and gender? Why should gender identity be given precedence?
Conversely, if gender identity refers to nothing in the physical world, why should it have implications for how we interact with one another? If gender is purely internal, why is identifying as a “woman” any more meaningful than identifying as a “wixnoid?” Why are two people with similar gender identities more alike than say, two people that both have wombs?
When trans people say they identify with a gender, they often seem to be referring to a personal affinity for specific gendered stereotypes. For example, transgender wunderkind, Jazz Jennings, begins her illustrated memoir by saying that she has always loved pink. What, to her, is the significance of this fact? Is liking pink evidence for her being a girl? Are boys not allowed to like pink? According to Joyce, that often is the insinuation. In fact, when the prospect of a gay son has been thought to be especially dreadful, some socially conservative families have resorted to a peculiar open-mindedness about gender. In Iran, thousands of gay men have been pressured by the government into having sex changes. Similar treatment of both gay men and women occurred in apartheid South Africa.
More commonly, trans activists see no issue with boys liking pink. To them, the notion that gender identities can be decoupled with anything in the real world is a feature, not a bug. Historically, gender roles have been arbitrary, burdensome, stifling, and unfair. But strong rigid gender roles aren’t possible in a world where we can effortlessly hop between countless gender identities. In this way, gender identity theories can be seen as an intellectual pathway towards a post gender world.
***
Joyce thinks this is dangerous idealism. There are biological realities that separate men and women. Female bodies bring unique risks and unique burdens. Pretending that sex doesn’t exist does not make it so and can be actively harmful. She argues that, in recent years, British and American society has become deluded by the ideology of gender identity, and has rejiggered their institutions accordingly. Increasingly, sex-segregated facilities and organizations define sex using self-identification. This has extended not just to restrooms, but also to prisons, homeless shelters, and sport associations.
Outside of the internet, nearly everybody is supportive of preserving sex-segregation in certain contexts. Implicit in that support is the belief that for certain spaces, integration could pose safety risks or violate people’s privacy. Joyce argues that if we change the basis of sex-segregation to something that doesn’t make any sense, these are the exact harms that we will start incurring. Moreover, these harms will be most pronounced for vulnerable groups, like women and children, who are at greater risk of sexual assault.
Joyce believes that basing sex-segregation on self-identification is almost as bad as ending sex-segregation altogether. She repeatedly invokes the image of a convicted male sex offender with a crewcut strolling into a woman’s locker room, ogling everyone, and then claiming to “be a lady” whenever someone asks him to leave. But Joyce’s trans-exclusionary perspective goes beyond these scenarios. In her view, even trans women who underwent full medical transition should have to “explain their situation” and “ask for forbearance” to use female facilities (page 297). That is, unless they can pass as women, in which case, there is no practical means of stopping them from entering the “wrong” spaces.
Joyce has a similar take with respect to trans women seeking to participate in women’s sports. The entire basis of gendered sport leagues was to account for male physical advantages. Joyce describes the science behind why men dominate women in athletic competition. Women’s bodies, including their body fat percentage and hip structure, are evolutionarily optimized for bearing children. This leads women to have systematic physical disadvantages in nearly every sporting performance category. Joyce argues that even for trans women who medically transition after puberty, most of these advantages are preserved. And for trans women who identify as women while maintaining their natural testosterone levels, the male-advantage remains fully intact. This is another example of self-identification effectively undermining the benefits of sex-segregation. Again, the victims are almost always women, who are denied the glory of victory or sometimes even the opportunity to compete.
***
A separate focus of the book is a critique of pediatric gender medicine. Joyce covers the “desistance” literature, which shows that, when left untreated, most children with gender dysphoria eventually grow out of it. However, it’s becoming less common for gender dysphoric kids to be left untreated. Many of them socially transition, sometimes at very young ages. If the dysphoria persists to early adolescence, the professional standards of care recommend using drugs to suppress the onset of puberty. By age 16, the child can start receiving cross-sex hormones. Joyce is concerned that the long-term effects of this protocol are insufficiently studied. Moreover, the results of cross-sex hormone therapy are dramatic, particularly when started at young ages, and can lead to permanent loss in fertility.
People see puberty blockers as a moderate intervention for transgender youth because the physical effects are reversible. If kids change their minds, they can stop taking the pills, and experience the natural puberty corresponding to their natal sex. However, Joyce cites evidence showing this to be rare.
A UK study of 44 patients, aged 12 to 15, found that all but one recipient of puberty blockers eventually progressed towards receiving cross-sex hormone therapy. Joyce interprets these results, in combination with the desistance literature, as showing that puberty blockers cause persistence. Joyce believes that if the kids in this study were left alone, they would have grown out of their gender dysphoria. Instead, these children are subjected to a cascade of interventions, ending in surgery, and often leading them to become a life-long trans person. Joyce is unimpressed by the literature showing that children subjected to this protocol grow up to be highly functioning adults. In her view, they could have just as easily been highly functioning cisgender adults, spared the burden of rough surgeries and with their fertility intact.
***
Contrary to the cover blurb given by Richard Dawkins, Trans is not a “thoroughly researched” book. The book has no footnotes, which makes fact-checking Joyce’s claims an arduous process. It’s also difficult to verify if she is addressing certain lines of evidence, because the book has no index. There is a “further reading” section, but I sometimes struggled to find where she was getting her information, even after going through each listed reference for the entire chapter.
This might be forgivable if we could trust Joyce to be consistently forthright. Yet, Joyce betrays our trust as a reader by making verifiably false claims. For example, here is how Joyce introduces Harry Benjamin, an important figure in the history of transgender medicine:
“Harry Benjamin, a German endocrinologist who had invited Hirschfeld for a speaking tour of the US shortly before Lili Elbe’s death, had started his career as an out-and-out quack. He arrived in New York in 1913 as the assistant of a swindler selling the ‘turtle treatment’, a fake tuberculosis vaccine. That fraud was exposed, and Benjamin moved on to touting testosterone supplements and vasectomy as anti-ageing treatments.”’
-Trans, page 20
I had never heard this about Harry Benjamin before. I looked through her “further reading” section but could not find any support for her characterization of Benjamin’s early career.
The most detailed version of this history that I could find was in the The Sexual Century by Ethel Spector Person. Benjamin graduated with a medical doctorate from the University of Tübingen, a prestigious German university. His doctoral dissertation was focused on the treatment of tuberculosis. He was encouraged by Carl Ludwig Schleichm, a famous German physician, to go to work for Friedrich Franz Friedmann, who supposedly had developed a vaccine for tuberculosis.
Friedmann had developed the vaccine by passing strains of tuberculosis through turtles. Though the phrase “turtle treatment” might evoke snake oil, this is not a crazy idea. The vaccine for smallpox was synthesized by passing a milder-related disease through a cow. Inspired by this, early tuberculosis vaccine efforts involved attempting to pass the disease through animals, including rabbits, cows, and pigs. The early results from Friedmann’s vaccine looked so promising that he sold the U.S. rights for $2 million in 1913, which is more than $50 million in today’s dollars.
Benjamin accepted a job as Friedmann’s assistant and traveled to the United States to help introduce the medicine to the American market. Subsequent data did not show the vaccine to be effective. Friedmann asked Benjamin to “beautify” the results, but Benjamin resigned instead. Unable to provide findings that the vaccine was effective, the New York City Health Board shut down Friedmann’s clinic in 1913. Benjamin’s professional relationship with Friedmann lasted less than a year.
Joyce’s gloss on the above history is that Benjamin was an “out-and-out quack” whose “fraud” was exposed. I can see why that narrative is useful in her effort to portray transgender medicine as corrupt from the start. But it’s not true. Over the subsequent decades, Benjamin systemized transgender medicine, eventually publishing The Transsexual Phenomenon, a clinical treatment guide informed by extensive experience working with transgender populations. His core recommendation, that sometimes the best we can do is “adjust the body to the mind,” is still widely-accepted in contemporary clinical practice.
***
Joyce’s discussion routinely omits research that undermines her viewpoint. For example, she repeatedly asserts that allowing trans women access to female facilities would pose a safety risk to women. However, the only empirical research she provides to support this view is a reference to this report that found that 90% of “changing room sex attacks” happen in unisex changing rooms. The source article provides minimal detail on how this estimate was developed.
At least in the United States, there have been significant policy changes in this area. Famously, in 2016, the North Carolina Bathroom Bill required that people use restrooms based on the sex listed on their birth certificate. Many other areas have done the opposite, enacting trans-affirming bathroom regulations. Given these policy changes, you would think there would be some empirical research looking into whether public safety has been affected.
The best study I could find does exactly that by analyzing GIPANDOs. (I know what you’re thinking. Is it that hard to just say “gender identity inclusive public accommodations nondiscrimination ordinance?”) Between 1997 and 2015, a handful of Massachusetts localities began guaranteeing transgender people access to the sex-segregated facilities aligning with their gender identity. The researchers matched these localities to otherwise similar localities that had no such ordinances. Then, they compared rates of criminal incidents in restrooms over time between localities that adopted the ordinances and localities that did not. When localities started letting trans women use female restrooms, did bathrooms become more dangerous places?
No, they didn’t. If anything, localities with trans-affirming policies experienced a more favorable trend in the number of criminal incidents within bathrooms. Let’s not over-state this evidence. It’s a good paper, but it’s just one paper. The authors note, bathroom crime is rare, and that makes it hard to detect a signal. They also don’t report any evidence on whether the policy changes even affected transgender bathroom use patterns. With respect to this paper, I am only confident about one thing. If this paper had shown an unfavorable result for trans-affirming bathroom policies, it definitely would have been featured in Joyce’s book.
***
I’m not surprised that Joyce covered the puberty blocker issue. It’s a standard topic within the trans-concern literature. However, it’s hard to see how this topic relates to the rest of her book. There is no obvious connection between the treatment protocol of trans children and gender self-identification. Moreover, many of Joyce’s concerns would, at least superficially, be resolved if more people transitioned before puberty. Absent a first male puberty, trans women would likely fit-in just fine playing women’s sports or serving time in female prisons. Young transitioners typically pass so well, Joyce would probably never even notice them. If anything, Joyce’s advocacy stance on puberty blockers seems in tension with most of her other concerns.
I think Joyce’s hostility to blockers is emblematic of her general indifference to the subjective well-being of trans people. I’ll make this point by referencing two studies that Joyce herself cites within her book. First, the famous Dhejne study that used administrative data to track all sex-reassigned persons in Sweden between the years 1973 and 2003. This is the best existing study for understanding the prognosis of transsexualism under historic treatment protocols. The prognosis is bad. Compared to general-population controls, the people who transitioned over this period had higher mortality, suicidal behavior, psychiatric morbidity, substance abuse, and crime rates. The effect sizes were large. Transgender people in this study were 19-times as likely to die from suicide.
Now, let’s look at the Dutch puberty suppression study. There were 55 kids who were put through the protocol. Blockers at age ~14, hormones at age ~17, and surgery at age ~21. Like the Swedish study, the researchers compare the study participants to same-age controls from the general population. The study concludes that, post-treatment, well-being was “similar to or better than same-age young adults from the general population.
Imagine if you could go back in time, take those miserable transgender Swedes, and run them through the Dutch protocol? Could you transform a population with a 19x suicide risk into a psychologically normal population? For a moment, reflect on what a beautiful miracle that would be. Of course, it’s no sure thing. Maybe the Dutch kids were never going to be as unhappy as those Swedes. Or maybe that’s where they’re heading - the Swedish study had a much longer follow-up. Or maybe the best outcome would be if no one had transitioned in either study. The evidence on causal effects of gender transitions is so low-quality, that we honestly don’t know. Yet, a simple comparison of these two studies suggests that puberty blockers have the potential for a truly fantastical upside.
Moreover, Joyce’s “cascade of interventions'' hypothesis is essentially speculation. First, people who seek treatment for gender dysphoria are likely systematically different from people who do not, and those differences likely correlate with persistence. Moreover, the high desistance rates of gender dysphoric children on which Joyce’s argument depends upon are from studies of pre-pubescent children. As documented in the Slate Star Codex adversarial collaboration on child transitioning, many clinicians believe that gender identity starts to crystalize during puberty, which is why the guidelines advise against administering blockers before puberty starts. To my knowledge, there is no evidence suggesting that gender dysphoric 14 year-olds have high resistance rates, and both the Dutch and UK studies suggest the opposite.
I have my own kids. Sometimes, I wonder what I would do if my child had gender dysphoria and wanted to take drugs to suppress puberty. I think I would want to wait a bit, let them experience some of the effects of their natural puberty, and regularly check-in to see how they felt. The value of that information just seems too important to pass up altogether. But I wouldn’t want to wait too long and doom the prospect of them passing in their target gender. The decision for how long to wait would be a total nightmare because I wouldn’t know what to do. Also, my desire to make a thoughtful decision customized to my child’s circumstances would guarantee that idealogues on both sides would call me a child abuser.
***
Joyce claims that her book is not about trans people, but rather about the philosophy of self-identity and trans activism. Yet, Joyce makes many claims about the trans population. She curates stylized profiles and anecdotes about transgender people. Here are some excerpts to illustrate the types of trans-women that command Joyce’s focus (note: I’ve changed all the names):
Most people don’t personally know a trans person. That’s too bad, because knowing a trans person is very predictive of having a trans-affirming perspective on many issues. It matters even more than age, income, or education. Clearly, the trans folks that most people know are quite different from the colorful cast of characters that Joyce chooses to highlight.
For many of her readers, Joyce’s book will likely be their primary source of information about transgender people, and will probably lead such readers to adopt generally more regressive attitudes. Joyce might think trans people get a little too much love as it is, so maybe she is okay with that. However, many people actually have a more regressive attitude towards trans people than Joyce. Half of people think just being transgender is wrong. Roughly one-quarter don’t think trans people should be allowed to have children or be able to serve in the military.
And the policy environment here is very dynamic. Only since 2020 has the United States adopted a nationwide prohibition on employment discrimination against transgender people. Before January 2021, the United States had a blanket ban on transgender military service. In thirteen countries, being transgender is explicitly illegal. On all these policy questions, I suspect Joyce would take a trans-affirming position. Yet, her book is so loaded with anti-trans affect, that I suspect her impact will be to push people towards the anti-trans vote on every issue.
***
This book is about Trans identity. The Trans identity that I am most deeply familiar with is my own. So, I am going to close by talking about myself. From my earliest memories, I have always had a strong desire to be female. When I felt male, I felt bad. When I felt female, I felt good. I don’t know why these things caused me to feel good or bad. That’s just how I am built.
Day-to-day, I did not have much gender dysphoria. Mostly, it was concentrated in a handful of episodes. In those instances, I would feel furious at myself for having chosen to live the wrong life for so long. I imagined myself on my deathbed, regretting everything. “Chill out. Go to sleep. You’ll feel better in the morning,” I told myself. And I almost always did.
But, as these feelings kept recurring, I started wondering if my transition was just inevitable. As horrible as it would be to transition in my late-20s, what if not doing it just meant transitioning in my 40s? Or my 50s? I knew I wouldn’t pass, but I was hopeful people might be able to look at me without giggling. I was worried that if I waited much longer, I might not even be able to manage that.
So I did it. I came out, and practically everyone responded well. I felt confident. I had made the decision with my partner, who was supportive. I was financially secure. And I thought that I had done a nice job of cultivating realistic expectations for myself. I genuinely believed things were going to go well.
Then, something happened that I had not expected. After transitioning, my dysphoria got much worse. I started obsessively taking selfies. Before, almost all of the pictures on my phone were of my daughter. Now, they were all of myself. In my coming out letter, I had told people that I wasn’t planning on policing pronouns. “I prefer she/her, but if you forget, it’s no big deal.” But I found out that I was wrong. Though I didn’t want it to be, it was a big deal. I never minded male pronouns before I transitioned. But for some reason, being called “he” while wearing a dress hurts so much more.
I started severely restricting calories, dropping my BMI from 25 to 19 in just a few months. This helped me look better in my new clothes. I practiced my make-up, took voice therapy, received laser hair removal, set my alarm early to work on my hair, and swallowed estrogen. I thought that if I tried hard enough, that it would just feel natural for people to use “she.” And people did start mostly using female pronouns.
Yet, I still felt bad. As the “he’s” became rarer, the strength of the illusion that I was fitting in as a woman increased. Then, when the “he” finally came, it hurt that much more. Every interaction started feeling super higher stakes. I remember once going into a grocery store late at night. I was on my way home from a wedding. I really thought I was looking beautiful that night. Then, the cashier at the grocery store said, “thanks sir.” I was a wreck for days.
One time, I was talking with a bunch of family members, including one of my uncles. Him and I have always connected through logical and frank discussion. When the conversation turned to my transition, he said “it’s hard for me to remember to use female pronouns, because I don’t see you as a woman. You just don’t seem like a woman to me. You seem more like a man.” In front of everyone, I broke down, loudly sobbing.
“That’s not true! I see you as a woman”, my mom said. She turned to my uncle. “Look what you’ve done! You’ve upset her. Tell her what you said is not true!”
I knew who was telling the truth. I realized how weak I had become. I had given the whole world so much power over me. Anyone could destroy me with a word. I had also ceased being an interesting person to talk to. All I ever thought about was trans-stuff. All in the name of trying to achieve something that just wasn’t possible for me.
So, I went back to using my real voice. I started sleeping in and not worrying about the make-up. Increasingly, I wore jeans and t-shirts. After this, I didn’t need to worry about what my waiter would say. The “he’s” would come, but I just wasn’t invested anymore. Moving to this approach changed my life. For me, the recipe for being trans and being happy, was to accept certain hard truths. I’m never going to be a woman, like my sisters are women. Some people are always going to see a male when they look at me. Those are the facts of my life. It’s still a good life.
***
As much as I genuinely hated the experience of reading Joyce’s book, my personal experience leads much of her central message to resonate with me. From my perspective, being trans is nothing like The Matrix. It’s not a deep self-knowledge of some secret non-physical element of reality. It is just a base desire to be like the opposite sex. It’s not even much of an identity. It’s more like a body image problem.
Second, when trans people condition their happiness on becoming a true member of their target sex, they are setting themselves up for a lot of emotional torture. The reality is that us trans folk will, at least in some important ways, always be different than natal members of our target sex. I really wish that wasn’t true, but that’s life. We don’t always get what we want.
For me, internalizing some of the hard truths that Joyce covers in her book was good for me. It helped me move on and live a better life.
