What follows is an imagined conversation between me now and let’s call her Joan, a 33 year old trans woman I knew decades ago, who died by suicide following the breakdown of her relationship. She was one of the first trans people I really got to know early in my own transition and someone I very much looked up to. At her best, she was funny, charismatic, intelligent, confident, outgoing, and a very good friend. She knew how to listen and make you feel like she had your back. At her worst she was moody, reckless, erratic, and depressed, though I didn’t realize how depressed until it was too late.
Joan was a strong voice in the trans community and her loss sent reverberations through our mid-sized city for many years following her passing. Her partner rallied her friends and family for a memorial by the ocean. Joan had loved water all her life. We came together to share our memories of her by a bonfire on the beach. Afterwards, her partner played a video that Joan had recorded prior to her passing, to say goodbye to the community. She was thoughtful even at the end, always thinking of ways to encourage everyone else.
I remember her swaying this way and that in the video, clearly in distress, speaking slowly, heavily, like she had nothing left to give, telling us to love each other no matter what. Then the screen went black. I remember stepping out into the ocean air feeling heavy with guilt, for not having been able to be the friend to her that she’d been to me. For failing to give her enough of a reason to live.
I imagine if she were around, she would be confused by my change of heart regarding trans care. She was all for reducing medical gatekeeping back then. She was all for bodily autonomy. Would she understand why I have more questions now than I did back then? It was so easy in those days, to see clinicians as big bad gatekeepers who had no business telling us what we should do with our own bodies.
Would she see me as someone who is betraying my community now, by calling for more assessment and less medicalization? Or would she be able to see that what I am trying to do in my own imperfect way is an attempt to prevent unnecessary suffering and enhance wellbeing?
Gender care was sold as life-saving care to her, to me, and to a generation of young people. But it didn’t save Joan; it didn’t save Bobbie either (another friend who chose to die years after transitioning); it didn’t save me (though, thankfully, I’m still alive and still coming to terms with what I believe to have been a misdiagnosis of my distress).
When I think of Joan, my heart still aches. She was a beautiful human who deserved a long, happy life regardless of her gender. I don’t know whether her transition contributed to her death. Maybe it had nothing to do with it; or maybe it was one element among many. Either way, she isn’t here anymore to engage in conversation, and the world is a poorer place because of it. But where reality fails, the imagination is another avenue of connection. So let’s dive in.
A note for those readers who may have suicidal thoughts of your own. Help is available. Please reach out to resources in your community.
We walk into an oyster bar together, her first then me, and find our table. She is wearing blue coveralls and a white T-shirt. The table is carved out of driftwood and by a large window. I slide into the wooden bench. Joan sits down across from me. The menu is printed on a paper placemat in front of us, one for each of us. I already know what I want. It’s the same thing I ordered the last time I saw her. A breaded oyster burger and fries. It’s early enough that only a few other people are peppered throughout the restaurant.
Me: The way you left. It was a coward’s move.
Joan: It’s OK. Part of me thinks that too.
Me: How could you do it?
Joan: Life was unbearable.
Me: It was a selfish move.
Joan: It would have been more selfish to stick around and be a burden to everyone.
Me: I wanted to hate you.
Joan: I get it.
Me: You never mentioned feeling suicidal to me, ever.
Joan: What good would it have done?
Me: And yet you listened to me rail against my family, talk about how my life was pointless. You didn’t tell me to stop. You didn’t tell me you needed help. You didn’t tell me that you also felt like dying; that you were planning to. Do you know how much shame I carry? How betrayed I felt?
Joan: You didn’t know. There’s no shame in that.
Me: Why didn’t you tell me?
Joan: I wanted you to live. I didn’t want to push you over the edge. I cared about you. You had enough going on.
Me: So you thought killing yourself without warning was the better solution?
Joan: I just couldn’t keep going. I know it’s hard to understand.
Me: I want to hate you but in some ways you saved my life.
Joan: Yeah?
Me: The pain of losing you, of seeing the pain of everyone you touched. So many lives shattered after you left. I couldn’t do that to my worst enemy. For a time, my own suicidal thoughts dissipated, because of you.
Joan: That’s good then.
Me: But then, years later, the thoughts started to resurface. Crazy, right? Nothing sticks.
Joan: You stayed alive though. That stuck.
Me: Do you know, I hated you more when the thoughts came back. Because if you’d been there, maybe we could have helped each other through. That’s what people do; we stay alive for each other.
Joan: I did try.
Joan scans the room, taking in the people around us. Some of them are scrolling on their phones. That wasn’t a thing back when we last saw each other. The world really had changed. Some were in deep conversation. Her gaze is piercing, the same way it was that last time we met. On that occasion, she’d commented that she liked going to public places and people-watching, imagining the lives of the people she observed. She’d made a comment about how everyone seemed so lost. I remember gently reprimanding her for judging everyone based on nothing but conjecture. That was the closest she ever came to expressing her own sense of being lost.
Joan (munching on a fry): Why did you want to see me now? To tell me how angry you are, still? It’s been more than two decades.
Me: No. No. What’s done is done. You’re dead. I’m not. Who cares if I’m angry.
Joan: So what then?
Me: I want you to know what I’m doing now.
Joan: Okay. What are you doing now?
Me: I’m advocating for better assessments for people who want to transition; for people who have gender dysphoria.
Joan (frowning): Oh-kaay.
Me: I no longer believe that medical transition is the only or even the best treatment for gender dysphoria. I don’t think there’s a magic bullet. Everybody’s situation is different. It means we have to assess. We have to understand how people come to their understanding of themselves as trans. We have to understand what they mean when they say they are trans.
Joan: Okay.
Me: I’ve heard too many stories from people getting pushed onto a medical pathway without a thorough mental health assessment. Without a full understanding of the context within which their identity developed. Sometimes the results are disastrous.
Joan: Are you still trans yourself?
Me: Yes, I am. But it’s not an identity I hold all that tightly anymore. I’ve given it a lot of thought. It would be too disruptive to detransition at this point in my life. I have a career, a relationship, a social life, a legal identity, an academic identity all established as male. I’m not going to throw all of that away just to prove a point. But I live under no illusion that I am male. I’m just a gender nonconforming woman, a masculine female who tried to find a way to live a regular life and not draw too much attention to myself. Transition helped me with that. But it didn’t change what I am, fundamentally. I am a woman who took testosterone and now resemble a man.
Joan: So, you want to stop transitions for everyone else?
Me: No. I’m not that presumptive. I’m not the arbiter of what’s best for everyone else. But I do think that we owe people the truth. And the truth is that the higher the quality of evidence we have, the more dubious the positive outcomes are. Every single systematic review finds the same thing — that medical transition does not improve mental health outcomes. This care was delivered recklessly for years. We need a course correction.
Joan: It helped me.
Me: You’re dead at 33. Did it really?
Joan (frowning angrily): It’s not my transness that killed me.
Me: You chose to kill yourself, Joan. Don’t put that on anyone else.
Joan: I’m not. But if I hadn’t been able to transition, I’d have been dead sooner.
Me: You really think that?
Joan: Of course I do. Do you have any idea how hard my life was before I transitioned?
Me: Well no. You never told me.
Joan: I hated my body. I just wanted to wake up and be a girl. I’d go to bed at night, close my eyes and try to will myself to be a girl when I woke up in the morning. It never worked. I thought I was a freak. Everybody treated me like a freak. I was suicidal long before I died.
Me: Were you bullied?
Joan: Hell yeah. Incessantly.
Me: But that’s the point. Wouldn’t it be better to deal with the bullies than turn you into a girl?
Joan: Even if there were no bullies, I’d have wanted to be a girl. Besides, we live in the world we’re in, not the world we want. We can’t change other people. But we can change ourselves. Becoming a woman was the best thing I ever did.
Me: But you weren’t a woman. You were male. Just like I am female regardless of how I look now.
Joan: Semantics. I wanted to live my life as a woman. I did that. I had some of the best years of my life as a woman. (frowning) And some of the worst.
Me: If you could have found a way to be a feminine guy—-
Joan: I didn’t want to be a feminine guy. I wanted to be a woman.
Me (shaking my head): Sometimes we don’t get what we want.
Joan: Why did you want to tell me about what you’re doing? Did you think I’d be happy for you?
Me: I don’t know. I thought maybe you’d be able to tell me where I’m wrong. Or, maybe I hoped you could tell me you understand.
Joan: Look, I can’t give you what you want. I can’t give you my blessing. You do you, but I think you’re wrong.
Me: How? How am I wrong?
Joan: Doctors don’t know who you are better than you do. They can’t tell you if you’re trans.
Me: I actually agree with you on that. But in my case, they kind of did tell me I was trans. Because if they’d told me I was struggling because I was autistic I’d have believed that too. And my life would have looked very different. When I told them I thought I was trans, they ran with it. They didn’t ask me what made me think that. They didn’t ask me how long I thought that for. They didn’t ask me how I learned about trans. They didn’t ask me what I thought it meant to be a man. They just started me on hormones. They seemed more sure of my identity than I was. For that matter, so did you.
Joan: What?
Me: I remember you meeting me at university and being so happy to have met another trans person. Your partner told me later how you’d come home excited and told her that you’d met another trans person in class.
Joan: So now you’re blaming me for your transition?
Me: Naah, not at all. All I’m saying is I wanted nothing more than a reason for why I felt so different. Everybody else seemed to have it figured out but me. Everyone seemed so sure of everything. I was riddled with doubts. Still am, in a lot of ways.
Joan: You were pretty suicidal before you transitioned.
Me: Yes I was.
Joan: Didn’t you even attempt?
Me: Yes.
Joan: That all stopped after you started transitioning.
Me: For a time, yes.
Joan: So in your case, transitioning was life-saving.
Me: Correlation isn’t causation.
Joan (smiling wryly): I’m not going to convince you, am I?
Me (smiling back): Probably not.
Joan: I should go.
Me: Sure. Leave. It’s what you do best.
Joan: I’ll get the bill.
Me: You have money in the afterlife?
Joan smirks, gets up and heads for the waiter, to pay the bill. I grab a final fry and follow her out into the street.
The conversation feels truncated. It hasn’t gone the way I thought it would. I don’t know what I thought would happen. This was probably a wrongheaded idea.
Me: Joan, I’m sorry. I should have let you be.
Joan (smiles, sadly): Don’t apologize. It’s been good to see you. Take care of yourself. Sorry I couldn’t give you more of my time.
Me: You gave what you could. I’m grateful for that. I’m sorry if I’ve disappointed you.
Joan: What do I know? We all just do the best we can.
Me: Can I give you a hug before you go?
Joan opens her arms and I wrap mine around her torso. She is smaller than I remember, her grip is lighter. We didn’t hug the last time I saw her. On that occasion, I remember watching her walk away and being worried about her, but not being able to put my finger on any one thing. Something just felt off. I let go, and watch her walk away. She turns a corner without looking back, and disappears.
I don’t feel a sense of resolution. I feel tired. I turn in the opposite direction, and start walking.