I drag myself into the treatment planning room of the behavioral health unit, drop my backpack on the floor, and pick up the freshly xeroxed census sheet to see what I’ll be dealing with for the evening. I scan the names and notice the sexes. A few non-binary. One “unknown.”
“Hmm,” I say to myself. “Unknown. That’s a new one.” If there’s one place that should know what sex a person is, it’s a hospital.
I count the trans-identifying patients. On any given night they make up twenty to forty percent of our unit, where nearly everyone arrives because of a suicide attempt or the intent to make one. For years I’ve wondered about this disproportion. The trans population is somewhere under two percent of the country. Even allowing for higher rates in psychiatric settings, a quarter of the census sheet in front of me is a head-scratcher.
The field has an official explanation, and everyone on the unit can recite it: minority stress. The population isn’t treated well. They face discrimination and rejection. If only they were more affirmed – pronouns honored, new identities supported, friction removed – the distress would lift and the suicide attempts would stop. Hence the slogan: life-saving gender-affirming care.
What troubles me about this explanation isn’t that it’s wrong. Discrimination is real, and it hurts. The problem is that it’s the only explanation permitted, and that it ignores a basic question people seem scared to ask.
Why do people kill themselves?
The answer is almost always a confluence of causes arriving at once: a divorce follows a recent move, a job loss coincides with a relapse, insomnia hits after the death of a loved one. The field knows this; it’s why every intake asks patients about a dozen domains, not one. Yet when the patient is trans-identified, we suspend what we know and flatten every possible motivation for suicide into one.
A Performance with No Off-Stage
But there’s an unnamed cause that the field seems afraid to look at.
Consider what a trans patient trying to pass actually does all day. Voice, pitched and monitored. Gait, adjusted and finessed. Posture, dress, mannerisms, all managed, all the time, in front of strangers whose verdicts are silent, continuous, and absolute. The questions my patients seem preoccupied with are not, mostly, questions about discrimination. They are audience questions. How do I look? Was my voice right? Did they clock me? Do I pass?
Anyone who has treated performance anxiety knows this pattern: dread before the exposure, hypervigilant self-monitoring during it, rumination afterward, and a growing need for reassurance in between. What differs is only the stage. A musician’s recital ends. The passing patient’s does not. Every grocery line, every elevator, every waiting room is an audition. The slight pause before a pronoun, the flicker of a glance at the Adam’s apple, the patient’s own continuous monitoring of pitch and cadence — these are the real costs.
Sociologists have been describing this for decades. Erving Goffman called it impression management: the constant work of presenting a desired self to an audience. Passing is that work at its hardest — a performance with no offstage. The strain isn’t just when the performance fails. It’s the stage fright that never ends, because the show has no intermission.
The fancy sociological name for it is dramaturgical stress. In plain language: performing a self is exhausting, and most of the suicidal trans patients on my unit are tired.
The cost of an endless performance is real even when no one is hostile. Flight attendants — not a persecuted minority — get worn out just from what sociologist Arlie Hochschild called “surface acting,” the work of displaying feelings they don’t actually have. Putting on a front depletes people, even when the room is friendly.
Once you allow that the performance itself can be the cost, the stories sound different. A patient spends an hour preparing to leave the house. Makeup carefully applied. Voice rehearsed. Clothing selected. Every detail calibrated. A stranger says, “Thank you, sir.” No sneer, no mockery, no trace of malice. The interaction lasts three seconds. The patient is devastated.
The minority-stress camp labels it a microaggression. But no hostility is required. The sting is the cost of a performance that didn’t land. And when a performance doesn’t land, there’s always someone ready to blame the audience. The problem was the “rough crowd.”
A Lifetime of Exhausting Roleplay
If much of this population’s distress is stage fright for a show with no end, then affirmation is not the cure. It is the one thing anxiety clinicians are trained not to give: more reassurance.
When a patient with OCD tells me the water tastes funny, that he’s sure he’s being poisoned, the easy answer is “The water’s safe. You’re fine.” And it works — for an hour. But it teaches him the question needed asking in the first place. Each “yes, you pass, you’re valid” runs the same loop: it quiets the question briefly while confirming its premise — that the question must be asked, that the verdict belongs to the audience, that worth is decided by whether they buy it. Affirmation doesn’t close the theater. It sells more tickets.
Helping a patient examine whether the role itself is the source of exhaustion is not conversion therapy. It is ordinary clinical work applied to a domain the field has declared off-limits.
We need to be honest. Promising a socially anxious person that they will feel less anxious once they present as the opposite sex is, at best, incomplete. The possibility that transition signs people up for a lifetime of heightened impression management and performance anxiety belongs in the informed-consent process, and in our research agenda.
So, how “life-saving” and “medically necessary” is gender-affirming care, really? The uncomfortable answer is that nobody knows, because the field attributed every ounce of distress to the audience and never asked what the show costs to run.
Tomorrow evening I’ll pick up another census sheet. It will list diagnoses, medications, allergies, legal status, preferred names, and pronouns. What it won’t measure is the psychological burden of performing a self non-stop. We measure almost everything. That may be the one thing we’ve forgotten.
Steve Andrews spent twenty-five years as an advertising creative director building campaigns for international brands and walked away in 2020 to become a Licensed Mental Health Counselor. He now works on an acute inpatient behavioral health unit where a disproportionate share of his suicidal patients identify as trans. A career spent engineering persuasive language taught him to recognize the same tools operating inside the mental health field. His book, Affirming Ourselves to Death, is forthcoming.
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Truly sad. The truth is really sad 😢
This is a very, very good article. The only thing I didn't like is, at the end, when it says, "So, how 'life-saving' and 'medically necessary' is gender-affirming care, really?" It's that, implicitly, that question presupposes that, at some point, gender-affirming care is "life-saving" (it asks the wrong question...).