In 2012, about two months after I attended the Philadelphia Trans Health Conference (red flag) where I had made a group of new friends (red flag) and had fallen in love with a non-binary person who lived with their polyamorous partner in Brooklyn (1,2,3 red flags), me and my new sweetie had a conversation about the possibility I may regret the testosterone injections my therapist had recently written a letter clearing me for.

I had scheduled with the therapist shortly after returning from Philly, so I had seen her for about 5 sessions total (red flag.) She had administered only one assessment to me in the course of treatment, tracking anxiety and depressive symptoms. We did not discuss or assess for the possibility of OCD, body dysmorphic disorder, PTSD, dissociative disorders, autism spectrum disorders, borderline or schizotypal personality disorders, all of which are conditions in which a patient may have the strong sensation of their body being incorrect and wanting to escape from their body (red flag.) Assessing for these conditions is recommended by the World Professional Association for Transgender Health’s Standards of Care. However, drawing from the recommendations of the presentations I had seen at Philly, during my first session with my therapist we had talked about our shared philosophical stance against “gate-keeping.” We agreed that the authority to deny me from deciding what I should do with my body should not be granted to her just because she was a licensed counselor, as that hearkened back to traditions of medical paternalism (red flag.)

I got the letter from my therapist, scheduled with the endocrinologist, and with my sweetie had the one and only conversation I’d have about regret before taking testosterone. My crimson-draped love interest told me they’d never heard of someone experiencing regret who wasn’t a fundamentalist Christian or a TERF. “I do have a friend who went on to identify as femme, but that just means they have to shave every morning,” they told me.

I loved Andrea Long Chu’s bizarre essay in the New York Times “My New Vagina Won’t Make Me Happy” because it showcased the default oppositionality and masochism that characterized my old radical queer social circle. In this worldview doctors and family members who express concern for the transitioning person’s wellbeing are actually expressing a need to control rooted in basic hostility. In this worldview it is more authentic for the transitioning person to prioritize short term, impulsive expressions of identity which expose them to danger than to use their executive functioning to plan and execute a transition in which they keep their job and home. In this worldview the individual taking responsibility for the future life their actions are creating is discouraged in favor of the individual acting out whatever current impulses are strongest.

Weirdly, despite doctors being viewed with the suspicion of wanting to be “little kings of other people’s bodies” in this world view the most respectful setting for the patient to receive transition care in is informed consent clinics, where the patients sign away their right to sue their doctors. While informed consent clinics are presented as the vanguard of patient autonomy, to get hormones at one you necessarily walk out with fewer rights than you walked in with.

These days I’m detransitioned, and have spent the past few years rebuilding from the losses a poorly planned and fundamentally unwise gender transition will inevitably accrue. The loved ones of gender dysphoric people pursuing hormones and surgery often write me asking how they can get their family members to acknowledge their own red flags. Longstanding patterns of identity diffusion, social skill deficits, struggles with emotion regulation, and obsessive-compulsive tendencies tend to be obvious to the people around us, and hard for the individual to recognize. Ideally this is what the therapy room can be: a place where it’s safe for us to see the ways we cause trouble for ourselves.

Ms. Chu repeated a popular accusation against science writer Jesse Singal in her essay: that he included the stories of detransitioners (including mine) in his July/August Atlantic story about care for gender dysphoric minors as a dogwhistle to communicate sympathy for an anti-informed consent viewpoint. I’ve had off the record conversations with Singal about the topic and frustratingly his off the record viewpoint is exactly the same as what he wrote in the article. Singal and I agree informed consent for adults is necessary to respect patient autonomy. We disagree in that I feel strongly it’s in the best interest of the patient to keep all their rights and avoid informed consent care.

Despite the fallout in my own life from the anti-gatekeeping viewpoint, I agree with Ms. Chu’s defense of the informed consent model. Adults have the right to make decisions the people around them would call bad bets. Access to informed consent care should be defended because of the importance of patient autonomy. At the same time actually getting your care through an informed consent clinic is an awful idea. It will not create good things in your life to skip the assessments the Standards of Care recommends. It is not a good move to cut yourself off from the relationships (like family members, old friends, and yes a competent psychotherapist) that alert us to our fantasies, our misunderstandings, our masochism, and our obnoxious relational habits. Gender transition is a pursuit fraught with all kinds of surreal difficulties. While you should, as an adult, have the right to kick off those difficulties tomorrow if you so choose, be kind to yourself and get a handle on your patterns before you embark on such a difficult and strange journey. My preference would be a healthcare system where it’s as inexpensive and geographically accessible to see a psychologist as it is to get hormones.

So why talk about or to detransitioners if it’s not a plot to shut down informed consent care? We’re worth talking to and about because we are a part of the landscape of people who experience gender dysphoria. Ms Chu states our numbers are statistically small, but in reality we don’t know how many people medically transition in America each year, much less how many people detransition. The one study that tracked regret found that out of 681 Swedes that legally changed their names and genders from 1960 to 2010, 15 of those Swedes applied to have their gender on their government documents changed back. That doesn’t tell us much about what’s happening in America these days, especially since my understanding is there were no informed consent clinics in Sweden during that time. If I was a Swede in Sweden from 1960 to 2010 I would actually not be counted as a “regretter” because I never changed my documents. I know right around two hundred detransitioners but I only know one who changed her gender legally and then changed it back. In large part detransitioners opt out of name and gender changes because the process is tedious and expensive.

Regardless, if we take 15/681 Swedes in Sweden from 1960–2010 and generously assume that that ratio (2.2%) will hold for America in 2018, we have no idea how many Americans 2.2% would be. A Williams Institute study in 2016 estimated that 0.6% of adults in the United States identify as transgender, or 1.5 million people. Identifying as transgender is distinct from pursuing gender confirmation surgeries, so we can’t assume 1.5 million people are pursuing medical interventions. Let’s say only a third of the people identifying as trans will pursue a medical intervention, and let’s say that 2.2% regret stat from Sweden would still apply in the current American context: the math says 11,000 people will experience regret. I think all of these numbers are wild shots in the dark, but regardless it’s rational to expect the population of detransitioners will at least match the rate of growth of the trans population.

I attempted to return to the Philadelphia Trans Health Conference in 2017, as one of the presenters of a panel on detransition. The planning committee cancelled the panel a couple of weeks before PTHC because, “When a topic becomes controversial, such as this one has turned on social media, there is a duty to make sure that the debate does not get out of control at the conference itself.” This was much like the reason researcher James Caspian was given by Bath Spa University that same fall when he attempted to study the experiences of detransitioned people. The ethics committee found that the “politically incorrect” nature of the research “may be detrimental to the reputation of the institution.” Making plans for the inconvenient aspects of the likely future has to take a backseat to avoiding controversy.

Earlier in 2017 I participated in a panel about competencies for mental health practitioners working with detransitioners at the inaugural USPATH conference. After the presentation one attendee, a gender therapist from the southwest, asked of me and a co-presenter, “Psychotherapists don’t have to write letters when patients want face tattoos, so why should we write letters for hormones?” There are many choices adults get to make concerning their bodies that make their lives trickier. And yet it was also a nice nod to the economic and social catastrophe gender transition, much like a face tattoo, can become. If you’re thinking about a face tattoo, think long and hard and get your money right first. Same goes if you’re thinking about transition.

It was a notable move for Ms. Chu to publish an essay six days before risky, life changing surgery arguing against the consideration of future happiness and the ethical principle of “first, do no harm.” It captured so many tendencies of the radical queer viewpoint- the veneration of impulsivity, the distrust of familial relationships, the conflation of individual self-harm with political defiance. Ms. Chu created the occasion for millions of strangers to be angry with her on the internet less than a week before undergoing surgery that in her own view creates a “permanent wound.” The audience for this performance is expected to communicate our political solidarity with her community by politely abstaining from noting that she just orchestrated an extremely high stress and surreal set of challenges to navigate for the next season of her life. It’s a beautifully masochistic power trip.

Like Ms. Chu, I found that my peers in the radical queer community accepted that their gender dysphoria and suicidal impulses would heighten in response to medical interventions. The normalized responses to suicidality in the radical queer community I ran with were: tweeting about being suicidal, engaging in BDSM, tweeting about engaging in BDSM, cutting, tweeting about cutting, and attributing all of these attention seeking and intimacy avoiding behaviors to a queer philosophical and aesthetic lineage. Unsurprisingly I did not find my sense of inner peace and self-efficacy increasingly in that social context.

Let’s be very clear: the radical queer community is not the context most trans people exist in. Radical queer philosophical propositions are not ones you can expect most trans people to be guided by. The backlash within the trans community to Ms. Chu’s essay bears this out. But I’m glad Ms. Chu put that viewpoint in the paper of record, so we can consider how to create clinical responses to gender dysphoria in which it is not ideological betrayal to acknowledge red flags.

The most stunning statement from Ms. Chu’s essay is “There are no good outcomes with transition.” This statement has no grounding in any of the outcome research that’s been produced, even the old John Hopkins era stuff people dismiss as transphobic. I know so many middle managers with homes and dogs who identify as “good outcomes” after their transitions. There are thousands of people who say hormones and surgeries alleviated their gender dysphoria. In recent years there’s also been a surge of detransitioners writing about alternative responses to their gender dysphoria that have alleviated the symptom. We have every reason to think that, like most human experiences, the etiology of gender dysphoria is complex. Psychodynamic, social, and physiological components probably all play roles in varying capacities for each gender dysphoric person. Since we’re dealing with a large patient population it’s also rational to expect different solutions will work for different patients.

What is not rational is Ms. Chu’s comfort with the proposition that misery is the gender dysphoric person’s birthright or her assumption that concern for gender dysphoric people must stem from a paternalistic need to control. It’s ok to prioritize becoming happy. It’s ok to want the people you love to take actions that protect their future happiness. It’s ok to point out the red flag everyone except the person waving that flag overhead can see.