Part I: Transition and Teenage Mental HealthMany people, including me, have the general impression that trans people are kind of crazy. Trans teenagers seem to be particularly mad. It is, however, hard to find good statistics on the problem. In most countries nobody official is tracking how many people consider themselves transsexual or transgender, so most of the numbers you might see are dubious. But the Danish government tracks its citizens with a true teutonic thoroughness, and they do have such a list. Which allowed researchers to discover the following:
- 43% of trans people have a diagnosed mental illness, compared to 7% of the general population;
- the rate of suicide attempts among trans people is 7.7 times the average;
- the rate of death by suicide is 3.5 times the average;
- even excluding violence the overall death rate for trans people is twice the average.
The numbers are small, so this is not a great data set, but it is the best one we have, and trans advocates in the US have long claimed that their suicide rate is high. The other studies I have found are much less comprehensive, but they point in the same direction. Kaiser Permanente recently did a study of its policy-holders in California, and they found the following:
We looked at mental health in transgender and gender-nonconforming youth retrospectively between 2006 and 2014 and found that these youths had 3 to 13 times the mental health conditions of their cisgender counterparts. . . . Among these young people, the most prevalent diagnoses were attention deficit disorders in children, 3 to 9 years of age, and depressive disorders in adolescents, 10 to 17 years of age.
The pro-trans Trevor Project found that "46% of transgender and nonbinary young people had considered suicide within the past year."
Equally bad data shows that trans people have high rates of alcoholism and drug addiction. I do not find this at all surprising; consider that one of the most basic tests of mental health is to ask, "Do you feel comfortable in your own skin?"
This same bad data also shows that there are a lot more trans people in recent generations than there used to be. For my generation the number was 1 in 1,000 or less; recent data on young Americans finds 2 to 3 percent identifying as trans, and up to 5 percent identifying as curious about it.
Which brings us to the question that I am going to write about, despite the risk to my personal reputation. I have tried to raise this topic with friends recently only to be shut down with some version of, "Only cranky conservatives talk about trans people and mental health, and you don't want to go there." The subject makes everybody mad, so no doubt somebody will soon be mad at me, but I have a very strong sense that it needs to be discussed as rationally as we can manage. I need to ask: how should we feel about the fact that the rates of mental illness, suicide, and early death are so high among trans people? And what should we do about it?
One response, which has been the general progressive response in the US and Europe, has been to say that what trans people need is what everyone needs: acceptance, support, compassion. This is what motivates people to do things that strike me as very strange, like giving double mastectomies to teenagers. They see young people in pain, and try to help. They see troubled people who believe that changing gender would help them, so they try to assist them along a path that everyone hopes we be a journey of healing. They believe the mental health struggles of trans people stem from lack of acceptance, from being condemned and attacked and bullied for just trying to be who they are. The way to fight suicide among trans people is with celebration and love.
There certainly is data showing that transgender young people report much more bullying than non-trans people. However, after years of reading all I can find about bullying I can tell you that being bullied is to some degree a matter of self-definition and all such numbers have a lot of problems. In terms of my personal experience, the two young trans people I have known best do not claim to have been bullied, and they both have serious mental health problems. So my position is that while bullying probably makes all of this worse, it is not the root cause.
The desire to offer acceptance is also what motivates people to push for trans-inclusive language like "pregnant people;" trans people, the argument would go, have suffered more than enough and shouldn't regularly be confronted with denials of their identity built into the fabric of our speech.
On the other side we have conservatives who seem to think that transgender is a stupid fad, the latest thing dreamed up by bored teenagers to tweak their parents. Something they learned from Tiktok or Instagram. Various Republicans in the US have denied that trans teenagers have an elevated suicide rate. When I first encountered this line of reasoning I was puzzled, because it absolutely does not match the intense seriousness I have seen in the young trans people I have known. (I should say that I have only known young trans people.) Maybe there are teenagers who declare themselves trans in a flip way, because it seems cool, but, if so, who cares? They will get over it. I am going to wave all of that off for now and focus on a different conservative argument: given that transsexuality is so strongly associated with mental illness, is it maybe something we should discourage rather than celebrate?
Imagine a 14-year-old of your acquaintance comes out to you as trans. Should you say, "How exciting that you are discovering who you really are! What can I do to help you along your journey?" Or should you say, "You should think really hard about that, because transition is a hell road littered with dead bodies and ruined lives. If there is any way you can live with the body and identity you have, you should cling to it, because it is your best chance for a halfway normal and happy life. Have you considered therapy?"
The question gains complexity from the parallel to being gay. Gay people used to ask this question of themselves all the time, and despite the much greater acceptance of homosexuality in our century, they still ask it. What many trans advocates want is what we have done a much better job of offering to gay people: a road that is neither self-denial nor darkness. After all, young gay people also seem to have higher rates of suicide and mental illness, although so far as I can tell the rates are not as high as the ones we are seeing for trans people.
There is also the issue of age. Transsexuality is rooted in a discomfort with our adult bodies, and those bodies take form long before legal adulthood. If you want to prevent a boy who identifies as female from developing a man's body, you have to intervene in middle school. Now, my attitude toward middle schoolers is that they don't have a single frickin' clue about life, so letting them choose anything important about their futures is an invitation to disaster. A certain amount of discomfort with changing bodies is also perfectly normal, and many teenagers are unhappy with the prospect of becoming a man or a woman with all that implies. This suggests to me that we should maybe wait and see if the discomfort goes away, as it eventually did for me. Besides, it is an old principle of psychoanalysis, going back to Freud himself, that people in the midst of a psychological crisis should not make important life decisions. But the hormones don't wait for the age of reason; progressive people have said to me that waiting until people are 18 before intervening condemns them to a false life in the wrong body, so the cost of waiting is too high. It is also, the (bad) data shows, as teenagers that trans people are at the highest risk of suicide.
Against that one might set the growing movement for "de-transition." Some people who transition in adolescence later decide that it was a mistake and return to the gender identity they were assigned at birth. The data here is even worse than the rest, but what I have seen suggests that about one tenth of people who transitioned over the past decade are trying to go back. Some of them have even sued the doctors who helped them transition. One of these people, the one who received a double mastectomy, said when she later sued her doctors that "all I needed was for someone to tell me I was fine the way I was." I would not say that the existence of de-transitioners refutes in any fundamental way the concept of transition; even if one tenth of trans people regret it, for anything to be 90 percent successful is pretty good. But for me it again brings the focus back to the age of the people we are talking about, as well as their shaky mental stability. Not transitioning may haves lifelong consequences, but so does transitioning.
(You may be thinking that I am leaving out something important by not making a distinction between sex and gender. Like, say, gender is how you present yourself in society, whereas sex is biological, and so we should not make a big deal about people changing gender. But there is no consistency at all among trans advocates about this, and so far as I can tell most use these words promiscuously. Trans is about who you are, not just how others see you. The subject of surgical transition is also much debated among trans people, with some saying that if you don't have surgery you are a fraud, while others recoil from it.)
I work hard to avoid coming to any conclusion that requires telling other people what to do. If adults want to change gender, why should that matter to me? I am also not much concerned about transition for people who have identified with the other sex since they were young children. But I am troubled by the nexus of teenage depression, teenage suicide, and teenage transition. The Danish numbers confirm that what we are doing is not working very well. I have no firm conclusions about what we should do here, but I think anyone who is celebrating teenage transition as a great and good thing is blind to a very painful reality. Many trans kids are severely depressed and there is no data I know of that says transition is a good way to help them.
Part II: Metamorphoses
But as important as the dilemmas of teenage transition are, my thinking about transition is fundamentally about something else. I am a theoretical sort of person, so I want to ask a different question: what is real? Don't worry, I will get back to mental health at the end.
What was classical philosophy about? Part was about ethics, but the biggest and oldest part was what we call ontology. The philosophers at the root of the western tradition asked the questions, what is most real? And can what is most real change? They had every sort of answer to these questions, from Heraclitus saying that you cannot step twice in the same river to Parmenides saying that change cannot happen at all. Zeno's famous paradoxes were all about showing that change is not logically possible, so it must be an illusion. Plato became one of philosophy's gods by developing a system that allowed ordinary, everyday things to change without altering the underlying reality of the universe, where important things do not change.
Nor was this limited to the Greeks. The philosophy of the ancient druids seems to have been built around a model of a world in constant flux, in which all things were constantly changing into other things. Much classical Hindu thought is taken up with these same questions, the relationship between the constantly shifting veil of experience and the other, deeper, truer levels of reality.
Consider Ovid's Metamorphoses, a long poem recounting all the many Greek myths in which people changed into trees, stags, grasshoppers, or strange things. It seems very clear to me that intellectually-minded people in the ancient world loved to talk about what could change and in what sense, and what if anything was permanent and unchangeable; I can imagine many of them leaping into a dinner party conversation about whether humans can change their sex and what that would mean.
Which is to say that the question of sex or gender change is not just about teenage mental health, but about the oldest questions of philosophy. Those questions are fundamental to our thought because they are basic to our lived experience. We all exist in a sort of dance with change, longing for some things to change while clinging to other things that we hope will never change. We wonder if we are the same people we were a decade ago, or somehow fundamentally different. We wonder the same about those close to us. One of our most persistent fantasies is a love that "lasts forever."
Especially in the modern world of fantastically rapid change people cling, for deep psychological reasons, to what they hope are permanent realities. One North Carolina grad wrote a whole book about hating Duke, which had been the only real constant in his life and therefore a rock to cling to when everything else was threatened. Many, many people want for male and female to be rocks where they can find stability.
There is no perfect alignment between people who dislike change and political conservatives, but there is certainly a connection. I would say that conservatives certainly seek out islands of stability toward which they can offer allegiance, and around which they can build their identies: God, nation, the "traditional family," and so on. So it is no surprise that many conservative people are deeply unhappy about the trans movement.
Trans is a project of self-transformation. Which explains, I think, both its connection to mental health and its explosive political ramifications. Who needs self-transformation more than the mentally ill? And wouldn't any project devoted to undermining the certainties of family life and personal identity anger conservatives?
Part III: Pregnant People, Feminism, and Female Identity
Changing sex is not the only kind of self-transformation one can imagine. You might, for example, change your ethnicity instead. Except that in our world this is forbidden. We have been treated over the past few years to a parade of "Native American" professors unmasked as white people who tried to self-transform into Indians. (1, 2, 3) We consider this offensive, and in certain contexts it is even illegal. Many black and Indian people absolutely hate this, considering it a new and sinister form of theft: you already took our land and our power, and now you want to take our identities, too? On the other side people who "pass for white" are often said to be "denying who they are."
I find this puzzling, because genetically the difference between ethnic groups is a rounding error compared to the enormous and very real genetic difference between men and women. "Race", so far as I can tell, is a modern invention, but sex has been the fundamental division of most animal species for 500 million years. So why can you change one but not the other? The answer I usually get is that while sex may have more biological importance, race has so much recent political importance that it cannot simply be waved away. For many progressives, the grievances of oppressed ethnic groups are the most fundamental and important issues of our time.
But it seems very weird to me to forget that sex is also a political issue and to wave away the oppression of women as something we shouldn't care about any more.
Many feminists feel the same way about trans men as Native American activists feel about white people "playing Indian." I think this has two sides, the political and the personal. On the political side they see this as an invasion of their world by agents of their oppressors, who now seek to appropriate whatever they have of value that men haven't managed to take in other ways.
But I want to focus on the personal side, because that is where I think the real issues lie. There are many women who have not taken any kind of feminist stand against transition but are made uncomfortable by trans women, and this includes many liberals and progressives.
Consider "pregnant people."
When it comes to humans, you all know, everything is about identity. Everybody identifies as something. I, for example, identify as a cool-headed intellectual who wants to explore difficult and important questions regardless of who is upset about it or bored by this kind of analytical excursus.
Many, many women identify first and foremost as women or mothers or grandmothers. NOT as people or parents or grandparents.
The point of this long philosophical detour is this: arguing that you can change your gender or sex is not a trivial matter, but touches on the deepest regions of biology, philosophy, and language. In asking people to recognize that you can change your gender, you are asking a lot; in asking them to recognize that you have changed your sex, you are launching a broadside against the way many and maybe most people understand reality.
Part III: Feminism
I am all for freedom. I generally think people have the right, as John Stuart Mill put it, to pursue their own good in their own way. I think people should be allowed to define their own identities and decide for themselves who they are.
But we are not alone. Everything I do affects other people somehow, even if only by leaving footprints. Freedom is never, therefore, any kind of absolute, but must always be negotiated with others. Your freedom does not extend to punching me in the face, or smashing the windows of my house.
I have a strong sense that if you want to be free, you should support everyone's freedom and never use your own quest for freedom as an excuse to tell other people what to do and say.
And this is what bothers me about the trans movement as it now exists: it is too much about defining an identity by forcing other people to recognize it. Claims of identity seem to function mainly as weapons in the culture wars, as a way to force our society to accept a certain view of human life and even of the universe. The trans movement sets the claims of their own self-understanding above all other claims.
But cis people have identities, too, and no more than trans people do they feel fully supported in them. What it means to be a woman, for example, is a hard social and psychological problem, and many assigned-female-at-birth people struggle for a sense of womanhood. And then along come trans people saying that the way most women use the word is wrong, because it excludes them. "Pregnant people" is a particular flash point, because there are women who struggled their whole lives with a sense that they were failing at being women until they had babies, and to be told that they can't make motherhood the center of their female identites really pisses them off.
There is a tendency among progressives to say that the claims of trans people must take precedence over those of cis women, because trans people are suffering far more. Which is, the Danish study shows, true. But everybody suffers, and in our world most people struggle to define and feel good about their identities. My gut reaction to trans people complaining about words like motherhood, is, "stuff it." Your pursuit of your own identity is no reason to attack other people where their own identities are most vulnerable. I follow the Buddha in this: the master virtue is compassion, and whenever you act without it, you fail in a fundamental way.
If you're thinking, John, how can you demand compassion from people who are depressed and bullied to the point of suicide? And I answer, because I demand compassion from everyone.
But compassion does not mean always supporting teenagers in whatever they want to do. If there is any consistent finding in mental health, it is that children who grow up without parents suffer horribly. It is the duty of the older and wiser to guide the young as best we can.
But what guidance should we give? Beats me. Because I think we are dealing with issues we don't understand at all, I have no particular stand on all the political questions being debated in the US. But I do have a very firm stand on this: since we do not understand teenage transition, and because the stakes here are obviously very high, shutting down rational discussion and debate is the absolute worst thing we can do. A world in which progressives are all required to defend trans teenagers in everything they do, while MAGA folks feel required to mock and abuse everything about them, is not one that will ever arrive at a helpful view. When people are suffering, it never helps to shut down conversation about why, and what should be done.
