This is an open letter to transmedicalists.
I’m being direct this time, because I don’t want to talk about you as if you are some faraway, distant other.
I’ve talked in the past about harassment that I’d experienced years ago from trans folks who identify as “truscum” (so, transgender people who believe gender dysphoria and medical transition are necessary to identify as trans — otherwise known as trans medicalists).
Most recently, I took to Twitter to vent about it. And, not surprisingly, a lot of you weren’t thrilled about it.
I’m not going to pretend that I’m not angry or hurt. But I don’t hate you, as some of you suggested. I just really, really want you to stop engaging in friendly fire.
Based on your responses, though, I wonder if you even realize that you’re harming anyone. I think you’re caught up in some of your own pain, too, and that doesn’t make this conversation easy for anyone.
So I’m taking a deep breath and doing what I should’ve done in the first place — unpacking, very carefully, exactly what I’m struggling with.
I’m going to explain why this “truscum” thing is upsetting for me.
And let me be clear: I wouldn’t expend this energy writing if I didn’t care deeply about our collective wellbeing and freedom.
Relentless optimist that I am, I like to think that someday trans folks might join hands around a campfire singing “Landslide” by Fleetwood Mac (I swear this song is a transgender anthem — just a personal, unrelated opinion of mine).
But I’d be pleased if we were just kinder to each other as a whole.
“Kindness? Is that what this is? A call for kindness?” Yes. For empathy. For reason. For patience. For unity.
It may not be as spicy as you’d like, but it’s what’s needed if we have any hope of turning the tides and moving out of the crosshairs and into a future where trans people can truly be free.
So why am I picking at trans medicalism, of all things?
Let me share a little bit of my lore here, for context.
The first thing you need to know is that I work in digital media. It’s important to mention this upfront, because it’s my public work as a transgender writer that got the attention of transmedicalists in the first place.
As early as 2015, I started receiving emails and tweets from self-identified “truscum” for a blog that I wrote about how much I hated the word “transtrender.”
I didn’t believe that the stance I took was especially controversial — but it drew a lot of attention to me as a trans person, and led to some targeted harassment, which continued for a while throughout my career.
The fact that I hadn’t yet medically transitioned led these folks to start asking invasive questions about my body.
They were barging into unrelated conversations on social media to tell folks I was an imposter, contacting my followers with conspiracy theories about my transition (I’d made it all up apparently), and otherwise trying to discredit my work.
And of course, I was misgendered.
Just to add a little salt to the wound, I guess.
The reality is, I’d never said I didn’t want to medically transition. It was that I couldn’t.
Initially, in 2014, I’d had issues with my insurance because I’d moved across the country.
After that, it was my mental health status that led clinicians to deny me access to transition-related care (if you’re curious about how this nightmare happens, I interviewed other trans folks with similar experiences, and I wrote about it here).
So while this harassment campaign was happening, I was privately struggling with dysphoria that I could do literally nothing about.
You’d hope that other trans people would see this as a rallying cry to demand better access to care. But these folks didn’t.
Instead, transmedicalists told me my lack of medical interventions made me invalid.
It shook me. It broke my heart. I felt betrayed by my own community; I thought if anyone was going to understand my struggle, it would be other trans people.
It didn’t stop when I finally accessed hormones, either. Instead, transmedicalists had decided I was lying about that.
When I posted a photo of me holding my testosterone gel, they suggested it wasn’t my prescription, and then they decided that because I hadn’t had surgery, I still couldn’t be believed either way.
Never mind the fact that I was desperately trying to access care the entire time.
These were my very first experiences with “truscum.”
I’ll be honest — never in my wildest dreams did I think that the folks harassing me would be other transgender people.
And it wasn’t just me, either.
I watched this happen many times to others as well, including some of the advocates that I deeply respect and young trans folks who had only recently come out — some who were still teenagers and deserved our protection, not our spite.
But this was their initiation into the community. And this was my initiation into yours.
So I’ll just be upfront and say… you all didn’t exactly make the best first impression.
And I know, I know. You might be thinking, “But that wasn’t ME! I didn’t harass you! What has this got to do with me?”
I understand why the generalization might bug you.
But when you tell someone that they have the ability to determine who is and isn’t transgender, some people will use that mentality to justify the exact policies, language, and behavior that materially impacts our access and wellbeing as a collective.
Whether you’re passively advocating for that or actively doing so, the ultimate result is that other people then feel emboldened to play “gender police.”
They feel emboldened to decide who is and isn’t “trans enough.” And that means people get hurt.
That’s the crux of the issue for me. Regardless of intention, you’re engaging in friendly fire, and bigots with even less discernment are only getting bolder watching you.
And I have yet to see folks who identify as transmedicalists acknowledge that this is happening, and that there are valid concerns here.
If you’re still with me here — and if you are, I appreciate it — I want to explain to you exactly why transmedicalism as a concept is so troubling to me, with the hopes you can better understand the pain that I’m talking about.
Not because I want to lecture you or that I think you’re incapable of googling this. It’s just that I recognize it’s possible that folks just didn’t take the time to unpack it in a way you could hear it, and instead they became reactive in a way that felt dehumanizing to you.
So let’s establish my starting place (or bias, whatever) here: It’s true that I don’t believe the presence of dysphoria is necessary to identify as transgender.
I understand that from the get-go, that can touch a few nerves. But I want to explain why I think that’s an important place to start from, regardless of how it makes either of us feel.
I stand by those points in part because I don’t think dysphoria is a helpful measure in the first place — which I’ll explain in a moment.
I don’t say this because I don’t understand the knee-jerk reaction that can happen when someone says they haven’t been dysphoric. Because yeah, dysphoria is painful. It sucks.
When I got my first rejection while trying to access top surgery, I began abusing alcohol to cope — it was not a fun time for me. The pain nearly killed me.
I know it’s hard to imagine someone as trans when they don’t understand that kind of pain, especially when it’s a pain you’ve known acutely for a very long time. I’m with you there.
I’ve reacted that way before, too. I’m human. Sometimes my first reaction to something isn’t always my kindest one.
In a perfect world, we would have some reliable indicator or litmus test for helping folks to figure out if they were trans or not — some singular measurement that erases all doubt. As a fan of simplicity myself, I get the appeal.
But the reality isn’t so simple — many trans people suppress those feelings of dysphoria, or they misinterpret them and struggle to connect them to their gender.
This can make it impossible to discern — especially as an outsider — if dysphoria is present. Requiring dysphoria to identify as transgender, for that reason alone, has way too much room for error.
A personal example: I’ve actually experienced some level of dysphoria for my entire life… I just didn’t know initially what it was.
I don’t want to do a deep dive into my history here, but suffice to say, the background that I came from made it very difficult to question my own gender safely.
So I experienced dysphoria, instead, as feeling profoundly self-hating and “ugly” (I wrote about this previously in this article, if you’re wondering).
No one else saw me as ugly or ever said I was, but it was a feeling I couldn’t shake. I felt like, no matter what I did, nothing made that feeling go away.
I just thought it was a stupid teenager thing. Except that “stupid teenager thing” didn’t go away and I became a self-hating, uncomfortable, gross-feeling adult.
If you had met me when I came out in 2012, you would’ve said that there was no freaking way I was transgender.
I knew I was miserable and I knew I hated how I looked, but “dysphoria” wasn’t a part of my vocabulary yet. While it had always been there on some level, I didn’t have any way to interpret what it meant.
And this isn’t an uncommon experience, trust me. Plenty of trans people come out and are still learning how to describe their experiences.
For those folks, it’s sometimes much, much later on that they realize there was some dysphoria happening for them. Sometimes the label comes first — and that’s valid.
I didn’t grasp how severe it was for me until after surgery. Only when my dysphoria was considerably diminished did I understand just how heavy it was to begin with.
It was a kind of misery I was accustomed to, to the point where I was the fish in the bowl that couldn’t really see the water. You know what I mean?
But now that I’m post-op, it’s like I’ve experienced a kind of joy and ease that I didn’t know was possible.
There’s also folks for whom their feelings of dysphoria progressively appear or worsen overtime.
I think of this as a kind of “hibernation.” People suppress all kinds of emotions, and dysphoric ones aren’t some magical exception.
But as they start to experiment with language, and explore their identity and expression, those feelings start to surface. As the outside world begins to reject them, that can trigger those feelings they’ve managed to push down as well.
Some people also experience dysphoria only in the form of dissociation, or a state of unreality, numbness, or disconnection.
They might not connect this to their gender at all, because it’s not an emotional state they can necessarily identify so quickly in the first place.
For trans people with other mental health challenges, trauma and mental illness might interfere with their understanding of their gender, and dysphoria becomes attributed to other causes (I also wrote about that here).
In other words, our brains work extra hard to try to protect us, which can make self-perception as a trans person a little wonky.
That’s what brains do with any kind of trauma. And this can show up as a total break from our own sense of dysphoric feelings, or misunderstanding the source or nature of those feelings. It’s more common than you’d think.
So when a trans person says they don’t experience dysphoria? It might be their truth at that particular stage in transition.
But that doesn’t mean it always will be. Those feelings could surface in the future, become better understood and recognized overtime, or progressively appear as it becomes safer to process them.
But if we accuse trans folks of being imposters from the start, we might closet them before they ever figure any of that out.
So for me? One of the big problems with transmedicalism as a concept is its potential to push trans people back in the closet and isolate them with dire consequences.
When you use dysphoria as this “infallible” meter stick, you actually end up excluding a lot of trans people who are traumatized or vulnerable, and arguably most in need of support, especially if they’re emerging from denial or dissociation.
Fact: Transmedicalists are more likely to harm someone who is trans than successfully cast out an “imposter.”
Because in actuality, more of us are traumatized than faking it.
When I first came out, I said that I didn’t want hormones and I wasn’t sure I wanted surgery. I am definitely the kind of “transtrender” that you would’ve rallied against (and, well, you did for a while).
Looking back, I have to laugh out loud. I can’t imagine not having medically transitioned.
With proper mental health care and, yes, incredible community support, I was able to get to a place where I could identify this resistance as a fear of rejection by society and my family especially. I was in deep denial because I was afraid of what would happen if I transitioned.
I didn’t want to lose my family. So instead, I lost myself.
It took a long time (and a lot of support) to really come to terms with that.
And even years later, I struggled with staying on testosterone just because of how vocal anti-trans sentiment had become and how much legislative changes made HRT inaccessible after I lost my 9-5 job.
And That’s the thing: I needed space, support, time, and compassion to be able to figure out my path.
As of 2018, I’ve been on testosterone for a few years now, which drastically improved my life and my mental health. And I’ve had top surgery, which was the single best decision I’ve ever made. I am so much healthier and happier now.
But when you use a singular measure like dysphoria to decide if someone is worthy of those things, you run the risk of doing a lot of harm to folks who aren’t “faking” anything — folks like me who needed to process things before they could make the right choice.
And there are plenty of reasons why medical transition isn’t an easy decision, too.
Some people can’t access it for financial reasons or are denied access by clinicians.
Some folks have chronic illnesses that would make medical transition risky or undesirable.
Some folks might consider it safer to remain closeted.
Some folks are in abusive environments where they can’t even begin to contemplate something like this.
And for some folks, right here and right now? They just don’t want to or aren’t ready to.
Maybe they’re questioning, maybe they’re afraid, maybe they’re overwhelmed, or maybe they’re just fucking tired. That could change and that may not… but it’s not up to us.
It’s not our business why and it’s definitely not our place to interrogate them, especially because we run the risk of doing serious harm for folks who might be going through some shit — shit that maybe they don’t even understand yet and can’t articulate.
You can’t know. It’s impossible for you to know. So what does that say about transmedicalism in practice?
It echoes the cliche about how everyone is fighting their own battle. Even and especially if it’s a battle you can’t see — because with trans folks, it’s the battles we can’t see that most often define our experiences.
So listen, I’ll give you this: Some disagreement over how we define “transgender” is bound to happen. It’s not the disagreement that I necessarily take issue with.
It’s miraculous (and incredibly rare) that anyone agrees unanimously about anything.
There are some people, for example, who don’t like Nutella, and that I will literally never understand. The difference here is that when someone tells me they don’t like Nutella, no one is actually being harmed in the process.
I acknowledge that there are going to be growing pains for our community, and I think this is part of that. These aren’t the first pains, and they won’t be the last. Historically, in every community ever, there have been divisions and disputes.
What I’m questioning here isn’t the definition of transgender. It’s what actually happens in the real world when we rely on your definition specifically.
Using dysphoria or medical transition as the way to define transness results in gatekeeping — and gatekeeping doesn’t work, because it’s too easy to get it wrong. And when we get it wrong? Trans people get hurt. Period.
The people who end up hurt most often (like, overwhelmingly so) aren’t actually faking anything and just wouldn’t benefit from doing so.
I was one of those trans people when transmedicalists harassed me in 2015. I was struggling to identify and understand my own dysphoria. I was being denied access to gender-affirming care by clinicians. I was struggling with PTSD and an eating disorder, which I would later uncover as being connected to, you guessed it, gender dysphoria.
It was a battle you couldn’t see, and instead of offering empathy, I was harmed by folks who should’ve stood by me.
Are there trans people who haven’t experienced dysphoria and never, ever will? As Acceptance and Access to care grows, Yes, Almost Certainly.
But regardless of your stance on this, I’m not convinced that the existence of trans folks who don’t presently experience dysphoria is justification for disbelieving people who come out.
Those folks might want to access transition-related care in the future anyway, because it could make them happier or healthier. They might uncover that they have been dysphoric as they learn more and gain more hindsight.
Which means that either way you slice it, you can’t know for sure if someone is transgender or isn’t, even by your own definition — because people change and grow all the time.
Otherwise, I apparently wasn’t transgender in 2012 but I was in 2014. I wasn’t transgender when I was too traumatized to grasp it, but I was when I was able to access and process my emotions.
Which… doesn’t make any sense.
Personally? I think gender identity is a diverse and complex thing — which to me is pretty exciting — but we might never agree there, and I don’t think, politically or ethically, we need to.
you don’t have to understand anyone’s experience to respect their process.
Folks need to be able to explore their gender identity without hostility, because we simply don’t know their internal reality and we never will.
The paradoxical reality is that the more fiercely you try to keep “outsiders” out of the trans community, the more likely you are to hurt trans people.
It’s not effective. It’s not helpful. It serves no other purpose than to hurt people.
So, earnest question: When someone comes out, why wouldn’t you believe them — or at least leave them alone — to ensure collective unity, to protect trans people’s process, and not give ammunition to anyone who would see this infighting as justification to revoke our access to care or undermine our freedom?
No matter how you choose to define “transgender” at the end of the day, the risks of upholding transmedicalism far outweigh any perceived benefit.
It’s far more important to make sure that anyone who is questioning their gender has options and support, and that those options are protected no matter what, than trying to suss out who does or doesn’t “belong.”
So the moment they say “I’m transgender,” I congratulate them and I move on. What the hell do I know?
That’s between them, their support network, their therapist, and whoever else they choose to involve.
Otherwise, there’s too good a chance that a transgender person who needs support will be denied it, just because of a misguided assumption about how they’re presenting in a particular moment.
We already get that from cis people constantly. Why would we reinforce it?
That’s why, when I define transgender as “identifying as a gender other than the one you were assigned at birth,” I do so with very intentional openness.
I want to be inclusive of folks who are questioning, and I want to give folks permission to evolve or change their minds, because that’s the only way to ensure that trans people can make the choices that are best for them.
The reality is, very few trans people emerge from the womb with an immediate and full understanding of their identity.
Looking back, it’s clear to me that I was transgender and had a pretty strong awareness of it as early as five years old.
But without support or access to information, it’s been a gruesome process to fully accept my identity as a transgender man and to access and embrace the care I needed and deserved.
Please seriously consider that people don’t make awesome choices when they’re being shouted at or put on the defense.
Or in my case, harassed. Transitioning within a community that feels like a pressure cooker, demanding a particular kind of conformity, is never going to lead to the best possible outcomes.
And honestly? Asking trans people to put the horse before the cart — to know what they need and who they are before they can entertain a label — isn’t how a lot of folks actually operate.
The label is often what connects folks to more information, support, and self-discovery. It helps them uncover what they’ve suppressed and who they might become.
So being possessive over the label actually winds up failing a lot of folks in the community, because they need the language before they can find a framework to operate from.
I want to say, too, that I understand it might be hard to let go of that impulse to judge.
When we identify with our struggles, it can feel insulting when someone who hasn’t struggled in the same exact way takes on a label that has so much meaning to us — a label that you feel you’ve earned, while others seem to just be sauntering right up and grabbing it.
Even so, I think we need to all agree — at the very, very least — that this is much more complicated than simply walking up to a label and dropping it into your identity shopping cart.
We’re talking about psychology, culture, language, trauma, biology, intimacy, sexuality, even spirituality — what aspect of the human experience is gender NOT touching on?
And that’s ultimately why I think reductionist definitions fail us as a community.
Gender is messy and abstract. If it weren’t, we wouldn’t be debating it literally all the damn time. The very fact that we don’t agree on this is simply proof that this is a complex thing we’re dealing with here.
We May never agree on what it means to be transgender. But I don’t think we have to — we just need to agree on how to treat one another.
You know, with respect.
So what do we do, then? For me, I’m just trying to do the least amount of harm. I’m asking you to consider doing the same.
There are so many different paths that people take to arrive at an understanding of themselves.
But if we close the door too swiftly on people who aren’t exactly like us, we run the risk of shutting the door on someone who needs us — someone with whom we might share a lot more in common with than we’d expect.
Personally, I don’t think people choose to be trans in a world that isn’t terribly kind towards trans people.
And even if they did put on some kind of weird act, I’ve accepted that I can never know that for sure, nor can I really do anything about it.
But I can be kind and gracious with the hopes that, wherever folks end up, they find the path that’s right for them. Extending that kindness to them doesn’t harm me in any way, shape, or form.
At the end of the day, it’s more important (to me, anyway) to create a community that allows trans folks to thrive. Gatekeeping doesn’t allow for that — it makes us suspicious of each other, callous, and combative.
If we want trans people to be able to come out, we have to make our community a safe enough place for them to do so.
When I came out in 2012, I had so many incredible trans folks to look to, and I owe so much of my happiness and health to them now. If I hadn’t had their support, I would still be closeted, if I’d even be alive today.
Every person deserves the chance to question their gender and explore it freely, without pressure, harassment, or gaslighting. This isn’t just a “be nice” issue — this is about the mental health and resilience of this community.
And I so badly want to believe that the majority of transmedicalists don’t actually approve of the harassment that folks like me have experienced, and don’t want to see what happened to me happen to anyone else.
I want to believe that if they knew the full story and really thought it through, they would’ve been there for me, as a trans person who knows how hard it is to be trans.
But the only way to guarantee that we aren’t caught in the snares of gatekeeping, and harming one another, is if we end this culture of interrogation altogether.
When in doubt, we need to do the kind thing instead, and let people live.
You may not understand where they are in their journey right now, but they deserve the freedom and dignity to walk that path and see where it leads them. They deserve all the time and space they need to figure it out.
They may or may not continue on that path — but it’s not for us to decide, and it’s antithetical to our liberation to play gender cop with one another.
I’ve given you all the benefit of the doubt here, because I believe every one of us deserves it.
The future of this community depends on us being a united front against anyone who undermines our freedom and bodily autonomy.
This was true when I first wrote this essay back in 2018, and as I revisit it again as the pressure cooker intensifies in 2025, I’m saying it again with my whole chest:
When will you realize that trans medicalism is antithetical to the freedom we’ve been fighting for all along?
Some of you are young, some of you are new to this, so take it from a trans elder who has seen this before.
When those in power are still pushing the myth that all of us are imposters, trans medicalism is just a nice way of announcing that you are happily complicit in your own oppression.
When you’re ready to fight for our liberation, I’ll be here to welcome you back in. You may turn your back on us, but I won’t turn my back on you.
With deep respect,
Sam
☑️ Up-to-date! This checkmark means that this content has been reviewed and updated since its original publishing date (updated: October 2025).
Photo by Karollyne Videira Hubert on Unsplash
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