On Happiness as a Metric for Transition
On April 10, 2024, Dr. Hilary Cass published her review into the practices of the only children’s gender clinic in the UK, the NHS Tavistock Clinic. This publication marked the end of a 4-year evaluation by Cass into the workings of the Tavistock and the efficacy of its treatment for British youths with gender dysphoria. The general takeaway of the Review is that steps taken for transition (both social and medical) do not improve the mental health of the population the Tavistock Clinic serves. In other words, transition did not make them quantifiably happier.
Per Dr. Cass’s recommendations, the Tavistock has since been shut down, and any medical interventions (including non-invasion ones such as puberty blockers) will no longer be accessible to trans minors. These treatments have not been banned entirely, however- cisgender children may still be prescribed puberty blockers for conditions such as precocious puberty. This is a major blow for both transgender healthcare in the UK as well as abroad, as many other countries use the British system as the basis of their own.
Suffice to say, there are a number of huge scientific and moral issues with Cass’s findings. Others have gone into depth analyzing this, and have done a much better job than I could. What I am particularly struck by, however, after reading through the full review, as well as various interviews with Dr. Cass, is her repeated insistence on increased contentment, happiness, or life satisfaction as a metric for a successful transition.
We are generally very familiar with the argument that transition is not of value to society, or indeed that it is detrimental. This discussion often occurs in the most exaggerated terms: transgender people are ungodly, unnatural, or perverse. The demonization of the trans community in this way plots it as an evil that must be done away with. In well-educated, liberal circles, we are able to discount this narrative immediately; its extremity is therefore what makes it less dangerous. While some dismiss and defuse the attack, others counter with responses that match its level of ferocity: the trans experience is beautiful, transition is magic, etc. It can feel satisfying to go to bat for trans people in this way, and important to reaffirm them of their value to society in no uncertain terms. There are issues that I see with this response, however, which I will go into later.
There is another far more insidious argument against transition, which is that it is of no value to the individual themselves. This argument is often couched in concern and care for trans people. Dr. Cass, for instance, is very careful to reiterate that her primary goal is to best serve children and young people with gender dysphoria, and that she holds no ill-will towards the trans population. She then makes the case that there is no quantifiable difference in happiness or life satisfaction in British youths before and after taking steps to transition, and that it has no significant impact on their dysphoria. To be clear, Cass’s findings were not that transition negatively impacted the mental or physical health of the youths that the Tavistock serviced, but rather that it didn’t seem to positively impact them, and that we can’t be sure of any negative outcomes in the future.
Again, our very natural response is to argue the opposite. When we read Dr. Cass’s justification for the closure of the Tavistock clinic, which is essentially that there isn’t enough evidence of the success of gender transition for youths into adulthood and increase in their comfort and life-satisfaction, our instinct is to press back with: “Of course transition makes trans people happier! Look at the evidence, here and here and here!”
However, I would argue that by defending transition on the basis of its attack, we only succeed in justifying the terms of this attack in the first place. We give transition its value through the negation of its criticism; it is not evil, but good, and it is good because it brings happiness to transgender people.
There are a few issues with this logic. First of all, when we talk about “transition” we use one word to encompass a huge variety of behaviors, ever-shifting and evolving, with entirely different significance for different people. What constitutes a gender transition for one person may have entirely different implications for another. For the sake of argument, let’s consider transition to be any social or medical changes that one undergoes to bring them towards a gender other than the one they were assigned at birth.
It is tempting to then personify transition as something that “gives” to an individual. In this case, “transitioning gave me a greater sense of self,” or, “transitioning gave me more comfort in my body.” Though this may seem overly pedantic, I believe it is an important distinction to make: transition is a tool- it does not “give” anything any more than a hammer builds a house. An individual’s increase in comfort, confidence, or life satisfaction is one that they develop themselves through transition, not the other way around.
Why does this distinction matter? To start with, it helps to demystify transness. When we bring transition down from the elevated dichotomy of evil/magic and break it down into its parts, we can view it with the same detachment and neutrality as any other procedure, development, or life choice. Instead of viewing a gender transition as one event, we look at it as a series of steps. Some of these steps are certainly medical, but just as many (if not more) are social, aesthetic, or internal. Having this more holistic view of transition also allows for greater understanding by the cisgender population; everyone is familiar with these shifts of identity. Changing career paths, for instance, or becoming a mother. At a time when transness has become incredibly loaded, I believe that actually this disempowerment of transition lightens some of its weight, and the burden of its justification.
Secondly, the argument that transition “gives” happiness is rooted in the assumption that transition is still, at its core, bad. Our insistence on justifying transness makes this so; we do not seek to legitimize that which we view as neutral. Take gayness, for instance. In liberal societies, we view homosexuality more and more as simple fact: some people are just gay. Our neutrality towards this makes affording gay folks equal rights very obvious. We don’t allow gay people to marry, or have safety in the workplace, because it will make them happier, we do so because it is their basic human right.
We have not yet reached this point of neutrality when it comes to the trans population, particularly in the medical sphere. Dr. Cass says the following in her interview with journalist Meghna Chakrabarti:
“We need to follow up for much longer than a year or two to know if [transgender people] continue to thrive on those hormones in the longer term. And we also need to know, particularly from young adults, are those young people in relationships? Are they getting out of the house? Are they in employment? Do they have a satisfactory sex life? What are the things that matter to them? And are they achieving those things?”
Are you, Dr. Cass? If not, shall we take a closer look at all of your medical decisions to determine where you and your doctors may have gone wrong, and kneecap the systems in place that gave you the autonomy to make those decisions for yourself?
The onus that we put on trans people to show marked improvements socially, societally, and sexually pre- and post-transition is still a reflection of the fact that we view transness as something in need of justification. To a certain degree this makes sense, of course; medical interventions can be costly and taxing emotionally and physically. These are not steps to be taken lightly, especially when we’re talking about minors and young adults, and we want to see some evidence of their efficacy. I believe, however, that we should be very cautious when determining these metrics of success, being sure to question if we hold similar procedures for cisgender people to the same standard.
It is also important to note: transition is difficult, but its difficulty does not make it inherently bad. Trans people are one of many populations for whom we must hold different medical and social considerations. As we’ve also found with the gay community, many of the difficulties of being part of a marginalized group are lessened or negated when these considerations are honored.
One of the other pitfalls that comes from falling into the metric of happiness as a measure of success is that it makes us reliant on it for our own justification, an argument which is a) dehumanizing and b) ineffective. To start with, no one should have to cower before doctors, or politicians, or family, bleating out the same tired stories (I was born in the wrong body, I was miserable pre-transition and joyous post-, look at all of the success I’ve found since transitioning) to access the treatment that they feel suits them. In a time where bodily autonomy is contested for many marginalized groups, we certainly do not need more of this paternalism in the medical or political realms.
On top of this, this narrative doesn’t even work. For those (like Dr. Cass) who are determined to view transness as, at best, a last resort treatment for those too hideously miserable to go on without it, no degree of pleading your own betterment will convince them of transition as an inalienable right. This is true even if one bows to their metrics of a “successful” transition; Dr. Cass clearly does not care how many happy trans people she encounters, her findings and outcomes would have been the same regardless.
The secondary danger of this narrative is the impact that it has on the psychology of the trans individual themselves. When we look to transition as a saving grace, and something with the power to give us our happiness, there is an inevitable betrayal when the rug gets pulled from under us. Some variation of: “transition was supposed to make me happier, and it has not. Therefore it was unsuccessful.” This then leads to anger, and feelings of deception, and subsequent despair: “If transition did not, as promised, make me happier, then nothing will.”
The reality is that nothing, transition included, owes happiness. You create your own.
The trans people in my life know this better than anyone. Transitioning requires an incredible degree of self-reflection, self-assurance, and independence. Again, transition does not “give” these qualities- they are developed and strengthened by the process one goes through in making and enacting the choices they feel best serve them. This process is absolutely grueling; it is no small thing to continually make the decision to put your own betterment over comfort, both of yourself and others.
So then if transition is so difficult, and does not even necessarily result in happiness, then why do it? Transitioning is the process of alignment- of identifying what changes need to be made to bring yourself into your body and subsequently, into society. It does not bring unrelenting happiness, or contentment, but simply the correctness to go on through one’s life, and the clarity of mind to engage with the world in the manner one chooses.
Being transgender is, by definition, a disconnect between oneself and one's perception in the world. This disconnect creates an enormous amount of friction. Pre-transition, the friction between oneself and the rest of the world makes engaging with society in a healthy way almost impossible. The outside world becomes something to fear, fight, or ignore as best you can. The internal world is not much better; there is also the same friction between how you see yourself and what is actually looking back at you. You, yourself, also become something to be feared, fought, or ignored. Having this constant misalignment creates a pressure cooker, eventually you either implode, explode, or open the tap and let out some of the steam. Through transitioning, one gains a baseline level of security that subsequently allows them to focus on building the life they actually want.
