Sometimes Outrage is Called For

 

Look, I avoid outrage-posting, because we live at a time in which outrage has been turned into a terrible currency, generated to glue us to our devices with indignation, which in turn generates polarization and despair.

But there is something worse than outrage, and that is the pooh-poohing of actually outrageous things.

This week, the US Supreme Court issued the terrible US vs. Skrmetti decision, holding that it is fine for states to ban trans youths from accessing as gender-affirming care he exact same medications and procedures that cis youths can and do access all the time to affirm their (cis) gendered comfort in their bodies and put off puberties that have started when they are not ready.

A large 2022 public health study found that accessing gender-affirming care reduced trans youths’ suicidal ideation by 73%. And trans adults who had accessed puberty blockers in youth have a reduced risk of suicide across their lifespans. There have been multiple related studies, but the Supreme Court said there wasn’t enough research to prove definitively that trans-affirming medical care provides benefits (ignoring what every major medical association has said). The Court also ignored the fact that all research studies on trans health that were being conducted in the US have been defunded this year by the Trump administration as “promoting gender ideology.” Ugh.

News of the Skrmetti decision has felt devastating to trans people of all ages, as it can be used to further erode trans rights for all of us. But it’s been a particular gut punch to trans youth, who have been declared in half of the US states to be deluded. Those state laws declare the proper treatment for that “delusion” to be requiring teachers and doctors and counselors to misgender them, and for any doctor or counselor who tries to provide them gender-affirming care to face legal punishment. Trans youth already face the highest levels of school bullying and parental rejection, which makes their risk of suicidal ideation terribly high—and now they face this decision on top of that burden.

On the same day that the Skrmetti decision was released, the Trump administration sent notice to the Trevor Project, which provides the suicide prevention services to LGBTQIA+ youths through the federally-funded 988 National Suicide & Crisis Lifeline, to stop work. So trans young people thrown into despair by the Skrmetti decision will find the suicide hotline that is supposed to offer them aid cancelled in the same way as their hope of access to medical care.

That is terrible, as many people I’ve pointed this out to agree.

But I've also personally received substantial "oh calm down" feedback and seen a lot of the same on social media about the cancelling of the Trevor Project hotline. Here's some of the things I've been told or heard:

"This is misinformation. Nobody targeted the Trevor Project specifically; the cuts are just part of a cost reduction across the 988 service and the service will still be there, just streamlined a bit."

"This is old news from months ago. It has nothing to do with some coordinated attack on trans people. You're putting unrelated random old and new stories together and catastrophizing."

"I think cutting the Trevor Project from the national suicide prevention hotline is appalling! But in case you didn't notice, the Trevor Project serves LGBT young people. Where is your outrage about the gay and lesbian youth? Why do trans people insist on making this all about them?"

This pushback is quite disheartening, because this is absolutely a case in which outrage is appropriate. Yes, leaked documents from the Trump administration earlier did state that a cut to Trevor Project services would be coming, but the stated date was in 2026. The administration chose instead to send the stop work notice much earlier, on the day the Skrmetti decision was released—and that is no coincidence. Here is what Rachel Cauley, the spokesperson for the White House’s Office of Management and Budget, had to say about it: the Trump administration will not “grant taxpayer money to a chat service where children are encouraged to embrace radical gender ideology by ‘counselors’ without consent or knowledge of their parents.”

Trivializing a suicide hotline as a “chat service” is vile and reprehensible, as is implying that the staffers aren’t truly counselors but something else—presumably “groomers” with malicious goals. But the fundamental message is the worst part. This spokesperson is literally saying that it is better to let trans kids kill themselves than to treat them respectfully in their identified genders.

Think about that.

And yes, this is specifically aimed at trans youth, as the Trump administration announcement states that the National Suicide and Crisis Lifeline will “continue to serve LGB+ youth” after the termination of the contract with the Trevor Project, under its general 988 line, using its regular hotline staffers. And yes, it is absolutely true that this is bad for cis sexual-minority youth, who are losing the counselors specially trained to help them. But the administration is explicitly saying it will serve LGB youth but not trans youth, because supposedly there is no such thing as a trans person. And it is hoping by acknowledging the existence of cis sexual-minority youth to get cisgender LGB adults to be motivated by self-interest to distance themselves from trans people (most of whom are themselves queer, mind you; only about a quarter of people who have gender transitioned identify as straight or heterosexual). Please, cis members of the Pride community—don’t let them divide us and set us at one another! Because the bigots are definitely focusing on trans people’s rights now, which must be recognized—but they’ll be focusing their destructive aims at cis queer folks in due time.

In sum, we can’t spend our lives in a continuous state of outrage, scrolling on our phones. That’s bad for our mental health, yes—but it also deadens people’s impulse to feel outrage when something egregiously abhorrent happens. We see how that has manifested this week, in people reacting to news of the cancelling of the Trevor Project’s national suicide prevention hotline services on the day of the Skrmetti decision. “This is misinformation! You’re catastrophizing by connecting unrelated new and old news items! This is a case of narcissistic trans drama demanding attention when all LGBTQ+ young people are equally harmed!”

Something truly hateful happened this week, and it is important that we treat it as outrageous—because outrage should push us towards action.

 

Why must I list the sex marker on my original birth certificate to get vaccinated?

 

A personal anecdote about going to the drugstore while trans. . .

I was born right after a vaccine for measles was introduced. In those early years of the vaccine, killed virus was used instead of live, and only a single shot was given instead of a series of two. So, the pre-Kennedy CDC urged people in my age bracket to get a modern MMR vaccine if there was a possibility of encountering measles (initially considered in terms of foreign travel or healthcare work). Now, medical news reports recommend that my age cohort get vaccinated.

So, I decided to get an MMR vaccine at my local Walgreens. I've been getting my vaccines at Walgreens rather than a nearby CVS because the Walgreens registration form to schedule a vaccine just asked me to indicate my "gender," while starting in the first Drumpf administration the CVS form began requiring that I check the "sex originally listed on your birth certificate." But recently, Walgreens started making the same registration demand.

I waffled over whether to ignore the new requirement and just list my lived gender. People of any gender get the same vaccines--they don't come in pink and blue sex-variants. There is zero medical reason for Walgreens to have to know my original-birth-certificate sex in order to vaccinate me. In any case, I was born intersex, and so my original binary birth certificate sex-marker was never accurate. And trans people living outside of large "blue" coastal cities receive medical care that is on average substantially worse in quality than that cis people receive in the US. When I am dressed, I currently have the privilege of being gendered correctly by strangers more often than not. Being balding and bearded thanks to testosterone access has a lot to do with that. Sometimes they recognize that I am transmasculine--but here in Wisconsin, sometimes they just presume I am a cis man. (Transmasculine people face a lot less scrutiny than do transfemmes, so my being 5'2" and pear-shaped can go overlooked fairly often.) Should I not try to conserve that privilege in interactions that could negatively impact my health? After all, I have dependents. . .

In the end, I entered the sex originally listed on my birth certificate, for the same reason that my backpack features trans pins and I wear t-shirts with trans-celebrating graphics and I post about trans topics on social media. As someone who has the privilege of often being properly gendered by strangers, it's important for me to be out, and not leave the hard work of trying to navigate and lessen transphobia to those who don’t have that privilege.

Well. I went to get my shot. I filled out my paperwork at the counter (with "Sex: F" printed at the top right corner next to my name) and took a seat in the waiting area. Twenty minutes later, my name was called. I got up and started walking to the pharmacy tech—young, with feminine makeup and long hair. “No no,” she said, “I’m not calling you.” I looked at her for a moment, then went and sat down while she watched. “Next is Cary,” she articulated loudly. I got up again, and walked over. “Your name is Cary?” she asked dubiously. “Yes, that’s me,” I said. She looked down at the form on her clipboard, where my name sat next to the “F” marker. She looked at me. “OK. . .” she said, and led me into the little vaccination cubicle.

Once we were in and the door was closed and I sat down, she had to go over the checklist of prevaccination questions—all of which I had to answer already on the form—but first she said, with a stony look, “Sorry, Cary is a female name so I was confused.”  I have a standard routine in circumstances like this, bringing up actor Cary Grant, but she never heard of him. So with a smile I said I am old, and many names change in how they are gendered over time, almost always going from traditional men’s names to gender-neutral ones to names seen as quite feminine. Lesley. Beverly. Meredith. Lauren. Taylor. “Really? Beverly was a boy’s name?!” “Yep,” replied I.

She didn’t mention the gender marker, though she did glance several times at my chest. (I wear a binder.) She just went ahead and gave me my shot. But she looked uncomfortable the whole time. Who knows what she was thinking. I didn’t ask, because it was a socially awkward situation, and there were a batch of people awaiting their shots. Getting a simple injection is a short medical interaction, and hard to get wrong, so it’s not like this tech’s discomfort posed a substantial risk to me.

But many other medical interactions do put a person’s health or life at risk.

Folks who are trans, nonbinary, intersex, and gender-nonconforming had been seeing improvement in the quality of our interactions with medical practitioners, but now that’s reversing, because institutions all over the US are caving and pre-complying with executive orders demanding disrespect for trans people that are all being legally challenged. And you see it even in the simplest of interactions, like going to get a shot at the local drug store, and having that experience become more uncomfortable.

It's important that we push back at things like this. There’s no reason to force people to misgender themselves to get a vaccination. Or to get a passport. The cruelty is the point, and we need a nation that is less cruel, not more! I know there are many worse things happening right now, from deportations to the attempt to destroy universities. But so much of our lives exist in little moments and short interactions. . .

This administration has turned a cold cultural civil war into a hot one, but we can mitigate that at least to some degree by being civil to one another. For example, if we’re unsure what’s going on with someone else’s gender when we’re dealing with their paperwork, we can just carry on being friendly and kind.

Do that!
 

On Bots and Trolls Spreading Transphobia while Pretending to be Leftists

 

This is a photo that appeared in the NY Times today in the coverage of the Supreme Court hearing on a Tennessee law banning gender-affirming care for minors. (Just over half the states have passed such bans in the past few years, though a number of those are not yet in effect while lawsuits take place. Some of these states--like Tennessee--have made it impossible for adults to legally gender transition as well, by banning changing one's gender marker on a driver's license or birth certificate.) 

Considering this photo, what I want to point out is something I've heard basically no discussion of in the mainstream media, and that is a core tactic being deployed by those opposing trans people's civil rights. There are three main such groups that are real: politicians and influencers who generate outrage for attention, clicks, and votes; transphobes motivated by hate; and foreign nations who deploy social media bots to say provocative things in order to promote division among Americans and weaken the country. But there's a fake fourth group that you find all over social media, and portrayed in big media events like the protests outside the Supreme Court today.

And that fake group is "concerned leftists." Often social media posts state that they are being written by a "lifelong Democrat" who feels compelled to speak up because the party has gotten lost and gone too far. Then that "lifelong Democrat" asserts something outrageous as truth, like "Kindergarten teachers are sending children for sex changes!" This is intended to horrify centrists. Another claim is aimed at progressives: that gender transition is a nefarious rightwing plot to convert gay and lesbian youth into straight people. 

You see both of these forms of propaganda in this photo in the NY Times. Two pre-printed signs read "STOP TRANSING GAY KIDS." And another preprinted sign you can partially see claims that the protest group is "DEMOCRATS AGAINST PUBERTY BLOCKERS."

I am not saying that TERFs do not exist--cis women who espouse a radical feminism for cis women only, and who frame anyone who has or had a phallus as inherently evil. But realistically speaking, they are a small group. This contrasts with what social media threads on trans issues often look like, where it appears that a majority of people opposing trans rights are "lifelong Democrats" and "LGB people" who just have to speak up as the voice of reason, before trans rights renders Democratic politicians unelectable or erases the (cis) gay community.

This is tactical. It is an attempt to convince people on the left that vast swaths of their fellow-travelers oppose gender transition. It is an attempt to move the Overton window to make overt transphobia seem the "normal" position on the left. And its effectiveness can be seen in how little it is noticed and discussed--even though it's hardly new. For example, an organization that played a key role in rolling back the rights of trans youth in Britain is the "LGB Alliance." Supposedly, this is a group of cis gay men, lesbians, and bisexuals who believe gender transition is a mental illness, and one that endangers the existence of LGB people by destabilizing sexual orientation. In fact, the organization is allied with neo-Nazi groups and American anti-LGBT groups, and says opposing same-gender marriage isn't homophobic. Oh--and a poll of people who joined the organization found that the vast majority of the members were straight. It's classic false-flagging, hiding the wolf in sheep's clothing.

As for the NY Times, they keep publishing opinion pieces in exactly this vein, by people who present themselves as LGB progressives who feel morally bound to take a stand against trans rights in the name of sanity, protection of the vulnerable, and preserving the future of the Democratic party. Ugh.

It is important for cis folks on the left to be aware of this tactic. Don't just take it at face value when you read some social media comment that a person spewing transphobic statements is the "lifelong Democrat" they claim to be. Don't believe that there is some huge movement by the cis gay community to ban gender transitions. Do be aware that there are trolls and bots trying to make you believe that you are behind on the trend of people like you reassessing their acceptance of trans folks.

It is important for all of us to be aware of how we can be manipulated!

On Flat Earth Studies, "Rapid-Onset Gender Dysphoria," and Bad Science

[Illustration by MidJourney]

In the past couple of years, almost half of the states in the US have banned the provision of gender-affirming care for minors. This explosion of transphobic legislation keeping trans youth from working with care providers who support them has been based on two central myths. 

One of these myths is about what sorts of care trans youths access. This panicky myth is that little kids are walking into clinics and being hustled into "mutilating surgeries" and dosed with "experimental and dangerous drugs." (The reality is that most of the care received by gender-dysphoric young people is supportive talk therapy, with a modest subset of patients accessing puberty-suppressing drugs that have been prescribed without controversy for many years to cisgender youths. Surgeries on trans youths are very rare, and most of these are chest reconstructions on 17-year-old trans boys. A vastly larger number of cisgender 17-year-olds get plastic surgeries on their chests every year to support their gender identities, as they are cis boys unhappy with the breast tissue they have grown, or cis girls unhappy with small or uneven breasts.)

But I want to talk to you about the second myth, which is that children are being rushed into medicalized gender transitions when in fact they have "rapid-onset gender dysphoria" caused by "social contagion." The claim is that teens go online and read that it is cool to be transgender, and decide to go along with the fad. Or a cool kid at their school transitions and gets social attention, so they say they're trans too. Then they are hurried into the "medical transition complex" with tragic results because this was just a passing immature delusion of theirs. The proof is that their parents report that their child was "normal" and gender-conforming, until one day they suddenly declared they were transgender and wanted to use a new name and pronoun and transition.

If you have ever tried to support a young trans person, it will be patently obvious to you that this is false. Coming out as trans is really scary for young people. Trans youths face a whole lot of stigma and harassment at school, and at home they may (rightly) fear that their parents will reject them. Only a third of trans minors report having parents who accept them in their identified genders. For this reason, trans youths often try to hide their identities from their families, and conform to their parents' desires for how they present themselves. So when they finally decide they can't hide anymore and must come out, or someone outs them, their unsupportive parents are shocked. As the senior mental health practitioner quoted in this Scientific American article states, “It is not [an issue of] rapid-onset gender dysphoria. It’s rapid-onset parental discovery.”

"Rapid-onset gender dysphoria" is not a real diagnosis. It has been rejected as such by the American Psychological Association. But again and again, when bills banning access to gender-affirming care have been debated and passed by state legislatures, "rapid-onset gender dysphoria" has been cited as proving the ban was necessary. This remains the case as we speak.

This brings us to the central point I want to make as a social scientist, and that is the problem of terribly bad "scientific reports" being generated and occasionally even published in academic journals, specifically in order to promote bigotry and conspiracy theories. The claim made by those who deploy these studies is, "You say science supports providing gender-affirming care to minors? Well, your science is wrong, and we have good science on our side! Your science is produced by corrupt gender ideologues and big pharma! Ours is produced by brave independent researchers!" And transphobic politicians are happy to dismiss the position of 98% of experts in the field, so long as they are handed some published study they can enter into the record.

And that is why it is important to note that one of the two "scientific studies" cited all the time now when transphobic bills are passed (because these two managed to get published) has now been retracted by the journal that published it, The Archives of Sexual Behavior. The reason the journal retracted the article is because the "researcher" who collected the data did not go through the required step of protecting the study subjects and getting their informed consent. But really, that is the tip of the iceberg.

Neither the retracted study nor the earlier study published in 2018, which coined the term "rapid-onset gender dysphoria," actually studied trans young people. Instead, they looked at posts in online groups made up of parents who opposed their children gender transitioning, and surveyed parents in these groups. This means the data they gathered was biased and invalid. 

The retracted study had two authors--one being a controversial psychologist who has been publishing long-critiqued homophobic and transphobic claims for years, Michael Bailey. (Bailey, for example, has framed being gay as a disorder that should be cured, prevented, or selectively aborted.) The second author was not actually a psychologist or academic at all. She used the pseudonym Suzanne Diaz, and is the mother of a gender dysphoric child who was a member of the group for parents who opposed allowing minors to gender transition from which she gathered surveys.

Now, let's be clear: it is ok for people to study subject pools with whom they sympathize! Doctors who are cis white men are "allowed" to study cis white men patients; jazz-aficionado sociologists are "allowed" to study jazz musicians. But researchers need to disclose their social position and potential conflicts of interest. They are supposed to lay out what potential biases they may have. And if 98% of researchers say XYZ, while the author's conclusion is that XYZ is wrong and in fact the opposite is true, they absolutely must acknowledge this and make a convincing argument for why the scientific consensus is incorrect. 

Most of all, surveying people from a group for flat-earth believers cannot tell you if the Earth is truly flat and not a globe. You have to study the actual Earth for the research to come to a valid conclusion. And academic journals should not be publishing invalid articles. This is especially true when those articles are being published in order to support a political campaign, and will impact the lives of thousands, unlike most scientific journal articles, which will only be read by a small pool of academics.

I am glad the Bailey and Diaz article was retracted. But it did great damage in the few years in which it was in print. We have to do a much better job of reviewing submissions that contradict scientific consensus. Sometimes a consensus can be wrong, and careful studies should prove that! But the burden of proof should be a high one, and publishing an article concluding that people may fall off the edge of the Earth based on interviewing people in Facebook groups for flat-earthers does not meet that burden.

 

Best Practices Checklist for Providing Medical Care to Trans Patients

I have been asked by some organizations to provide them with a pamphlet or list of best practices that they could share with medical practitioners regarding the care of trans patients.

I suggest as a substantial resource for outlining trans medical care standards  the materials provided by the Center of Excellence for Transgender Health, which can be accessed here.  

What I've done is write up a checklist that others can share with medical practitioners that is succinct and that includes practical suggestions highlighting key concerns raised by many trans people.  This checklist is founded on the presumption that transphobia is unacceptable in health care practice, and that care providers wish to provide high quality care to all patients, including sex and gender minorities.

Best Practices Checklist for Providing Medical Care to Trans Gender and Gender-variant Patients

Compiled by Dr. Cary Gabriel Costello

1. Members of your practice group have received cultural competence training in interacting with trans gender and gender-variant individuals, and medical training in the needs of trans gender and gender-variant patients. ( An outline of standards of care is available from the Center of Excellence for Transgender Health.)

2. Your medical records are kept in such a manner that the name the patient uses appears at the top of files. (If that name differs from the patient's legal name or the name on the patient's insurance card, it is the name that the patient uses which is first seen by any staff interacting with patients, so that the patient is always called by the name the patient uses.)

3. Patient records prominently display the pronoun that the patient uses, and staff are careful always to use that pronoun.

4. Sex/gender characteristics are recorded in the following manner based upon patient self-identification:

        a.  Patient's gender identity: male____ female____ self-designation_________

        b.  Patient's gender identity matches the sex patient was assigned at birth: yes____ no____

        c.  Patient is intersex/has a DSD/is physically sex-variant: yes___ no____

5. At least one member of your practice is able to supervise hormone replacement therapy for individuals who gender transition medically.

6. Members of your practice can present interested patients with a list of practitioners in the area who perform transition-related surgeries, including orchiectomy, chest reconstruction, and genital surgeries. Staff are aware that patients may wish to access all, some, or none of these services.

7. When a trans gender/gender-variant patient visits, the patient is treated with discretion, and attention is not drawn to the patient's status as a gender minority. For example, a patient's trans gender status is not discussed where other patients can overhear; other medical staff are never invited into the examination room to educate those other staff about trans bodies unless the patient volunteers to serve as an educator; pelvic examinations are never performed with the bed facing the door so that the patient's genitalia might be exposed if the door were unexpectedly to open.

8. When a trans gender/gender-variant patient is examined, practitioners use language to describe body parts that does not undermine the patient's gender identity; e.g. for a trans man, say “chest” not “breasts,” “pelvic exam” not “vaginal exam;” for a trans woman, say “genitals” not “penis.” If robes are provided to patients, they should not be gender-marked in a way that undermines the patient's gender identity.

9. Trans gender and gender-variant patients and the general patient pool are protected from uncomfortable situations in waiting rooms, testing facilities, etc. For example, the presence of a visibly trans gender person in a mammography waiting room can cause stress for the trans person and for the other patients. The solution to such situations should always center the patient's gender identity—for example, allowing the patient to wait in a private room. Trans women are never asked to wait in a room that says “men” and trans men are never made to wait in a room that says “women.”

10. Medical staff are prepared for patients to “come out” about being trans gender or gender-variant. Staff respond with composure and empathy, and focus on the patient, not on how member's of the patient's family or community will react. Staff are able to inform the patient about what medical transition entails if the patient is interested, and can provide the patient with a list of therapists in the area who work with clients who are considering medical transition.

11. Members of your practice are aware that children can have trans gender or gender-variant identities, and are able to refer these children and their families to appropriate pediatric and family therapists for support.

12. Treating trans gender and gender-variant patients respectfully and well is one of the criteria of medical staff review. Those who do so are credited; any staff who treat trans gender/gender-variant patients disrespectfully are disciplined.