More outrageous than The Economist asking in a tweet, “Should transgender people be sterilized before they are recognized?”—more outrageous still than Japan continuing to require transgender people be sterilized to have their gender identity legally recognized—is the fact that sterilization requirements for transgender people are not restricted to one country.

This week may have been the first you heard about transgender sterilization.

After Japan’s Supreme Court ruled earlier this year in defense of the country’s 2003 law requiring transgender people to have their gonads removed or rendered non-functional before being allowed to legally change their gender, the advocacy group Human Rights Watch released a groundbreaking report on the impacts of the outdated law.

“To get the surgery or have children—this is a decision that none of us should be forced to take,” one transgender woman told HRW in the report. “It is a despair.”

On social media, though, the report itself was overshadowed by The Economist’s since-deleted tweet, which seemed to pose compulsory transgender sterilization as an open question for debate—and for which the magazine’s parent company later apologized.

A spokesperson for The Economist’s parent company told Out that the question “was a line from the article that was mistakenly taken out of context.” But the effects of even introducing that question for public discussion did not go unnoticed by transgender people.

As Broadly’s Diana Tourjée noted on Twitter, the tweet seemed on its face to be yet another example of media outlet presenting transgender humanity as the object of a two-sided debate, rather than a self-evident truth.

But the transgender sterilization issue is much broader than any one country or tweet. In fact, many transgender people in the United States must undergo sterilizing medical procedures if they want birth certificates and driver’s licenses that reflect their gender.

When I underwent sex reassignment surgery, for example, I had to sign California’s “Consent to Sterilization” form [PDF]. I needed the surgery to alleviate my gender dysphoria, so I gladly signed the form despite how ominous it looked, but the operation also had practical impacts, too: I would finally be able to update the gender marker on my Georgia driver’s license.

Georgia, according to the Movement Advancement Project, is one of 10 states that still require transgender people to obtain proof of surgery, a court order, or an amended birth certificate in order to update their driver’s licenses.

Birth certificate laws in the United States are even stricter, per MAP data: 17 states require sex reassignment surgery to update birth certificate gender markers, and three bar any updates.

These state-level policies effectively posit that the only way to be a valid transgender person is to fully medically transition, often at great expense. Their cumulative effect is chilling: transgender Americans are often subjected to a cruel calculus, left to determine which medical treatments they need and which would further their legal recognition.

Although transgender Americans are currently able to update their gender on passports and with the Social Security Administration without undergoing surgery, the state-level patchwork of requirements for driver’s licenses and birth certificates puts thousands in the position of having to live without correct documents unless they want—and can afford—surgery.

Only 11 percent of respondents to the 2015 U.S. Transgender Survey said that they had their authentic name and gender on all of their identity documents.

That’s not as overt as Japan’s sterilization requirement, to be sure, but it’s a difference in scale more than it is a difference in kind. This is why, in the aftermath of the tweet from The Economist about the Japanese requirement, prominent transgender voices—like Rewire.News journalist Katelyn Burns—advised Americans to look in their own backyard for laws and policies that de facto require sterilization.

Indeed, the United States falls well behind the recommendations of human rights experts. As HRW noted in its report on the situation in Japan, organizations including the World Health Organization and the United Nations Program on HIV/AIDS issued a joint statement in 2014 that called for an end to “forced, coercive, and otherwise involuntary sterilization.”

The Yogyakarta Principles, developed by a group of human rights experts to guide the international community on LGBT rights, also state that “no one shall be forced to undergo medical procedures, including sex reassignment surgery, sterilization or hormonal therapy, as a requirement for legal recognition of their gender identity.”

Despite the positions of human rights groups, many European countries—like France—recently had sterilization requirements in place for transgender people that were finally condemned by the European Court of Human Rights in 2017.

Even still, that court ruling did not put an end to sterilization requirements across Europe. As of 2018, according to the most recent Trans Rights Europe Map developed by the umbrella organization Transgender Europe, some 14 European countries still require sterilization for legal recognition, including Finland and the Czech Republic.

That’s down from 24 European countries in 2013—but it’s still far from zero.

The answer to the question “Should transgender people be sterilized before they are recognized?” is, of course, “No.” The real outrage here is that the question continues to be asked, not just in places like Japan but across Europe and in our own backyard.