Above photo: Supporters of trans rights and their opponents rally outside of the U.S. Supreme Court as the high court hears arguments in a case on trans health care bans, on December 4, 2024, in Washington, D.C. Kevin Dietsch / Getty Images.
Everyone who cares about bodily autonomy should fight for trans health care.
When I had my first gender-affirming medical intervention, I was 21 years old. The year was 2005, and at that time, the idea of a trans surgery being covered by health insurers was outlandish.
So, I saved up money starting at age 18, and visited psychologists at the free gender clinic in the San Francisco Bay Area where I lived. I told them I had been “living as a man full time” and pretended to fit the clinical definition of gender dysphoria in order to get a letter allowing the surgeon to work on me. (I was genderqueer and nonbinary, had a high voice and feminine features and had virtually never “passed” as a man.)
I knew deeply and with utter certainty that having a double mastectomy would improve my self-image and help me live in an expression closer to who I am. So I jumped through all of their hoops, including the surgeon himself at the consult taking one look at me and asking if I was really sure about this.
I lay in a hotel bed in Plano, Texas, afterward, as happy as I have ever been. My dad, whose warm supportiveness was rare among parents of trans children at that time, visited me and took me out to the Cheesecake Factory while I delighted in my next body. It was easier for me than most people: I had family support, the ability to travel and pay out of pocket for treatment, and I was transitioning in a direction that afforded me more privilege over time as I became more masculine in appearance.
Years later, when I started hormone treatments, I was thrilled to find how much the medical community had advanced on trans issues, taking an “informed consent” approach with hormones rather than requiring me to pass an unpassable gender test. But of course, these gender tests are not required for cisgender people who want breast reductions, breast augmentations, plastic surgeries or gender-affirming hormone treatments, so long as these align with some societal caricature of their assigned sex at birth.
When I had top surgery back in 2005, people told me I was mutilating myself, that I was too young to decide, and that my decisions didn’t make sense to them. Now, I am one of thousands who can attest that accessing this care was life-saving and deeply affirming of my being.
My concern today is that trans people should not have to attest to this — because the “debate” over trans health care presented to the Supreme Court this week in U.S. v. Skrmetti will impact all of us, not just trans people.
At its core, this Supreme Court case is about the government’s control over gendered bodies. The case challenges a Tennessee law that bans trans youth from accessing gender-affirming care. But the proliferation of state laws attacking trans health care access shows that trans liberation movements have threatened a central ideological tenet of the Christian right and conservatism — gender essentialism.
The belief that gender identity is an innate biological category determined by our sex at birth is not a medical fact but a product of 18th- and 19th-century Western patriarchal thought — it is deeply entwined with the belief that “woman” is both an essential category and an inferior one. This essentialist belief system showed its weakness from the start, as it has long been forcibly imposed on unwilling communities via police and the military — through everything from sex-segregated spaces, to sexist rules applying only to women, to laws against cross-dressing and policing of gay and trans gathering spaces.
If gender were in fact essential and naturally aligned with sex at birth, why would it need to be policed at all?
In recent decades, even Western medicine has been questioning gender essentialism, prompted in part by activism from intersex and transgender communities. As many non-Western cultures have long acknowledged, a significant minority of people are born or grow up with ambiguous sex characteristics (chromosomes, hormones and secondary sex characteristics) and an even larger group of people do not grow up to identify with their sex assigned at birth. Intersex and transgender people’s existence shows that sex and gender are mutable and exist on a spectrum, and a vast majority of young trans people who receive affirming care attest that they are happy with the outcome.
In a desperate attempt to keep patriarchal gendered social systems from falling apart, conservative forces are now targeting these happy trans youth. They claim that young people are endangered by gender-affirming health care, even as they allow nonconsensual surgeries and hormone treatments forced on intersex children to continue unabated. The Tennessee argument in the Supreme Court quite openly holds that trans youth should be restricted from choosing health care that cisgender youth are freely permitted. The danger is not the hormone treatments — it is who is taking them, and how that upsets the status quo.
The argument presented by Chase Strangio of the ACLU and U.S. Solicitor General Elizabeth Prelogar asks simply that the Tennessee law be held to a certain level of scrutiny because it differentiates on the basis of sex. And yet the Supreme Court seems poised to reject that argument, with the court’s 2022 decision in Dobbs v. Jackson — which repealed Roe v. Wade and allowed states to ban abortion — serving as precedent for further restrictions of bodily autonomy.
Tennessee Solicitor General Jonathan Skrmetti made the connection explicit in his brief, asking the court to expand Dobbs to allow gender-affirming care bans at the state level. As Strangio told Slate, “whether you look at the equality thread or the autonomy thread in Dobbs, this is about structural efforts to impede people’s abilities to make decisions for themselves.”
Underlying both of these cases is an effort to curtail self-determination, particularly for cis and trans women, trans people in general, and low-income people (who are the most immediately impacted by all health restrictions, because they cannot afford to simply travel or move for care).
Legalizing the denial of bodily self-determination increases patriarchal control over all people deemed socially transgressive — in these cases, literally forcing poor people to carry pregnancies to term and give birth against their will, and to live in bodies and gender expressions that actively harm their mental and physical health.
The spectacle we are witnessing is not actually a debate about whether or not trans youth should be able to access hormones. These state leaderships do not care about protecting trans youth. They care about limiting and controlling gender transgression, protecting an antiquated medical definition of gender, and enforcing patriarchy as a biological claim on reality. Criminalizing trans care is a slippery slope, alongside criminalizing abortion, that we must oppose in a united front fighting for the health and safety of all.