When doctors always give patients what they want (or think they want), the fallout can be disastrous, as we have seen with the opioid crisis. There is every possibility that the medical treatment of young people with gender dysphoria may follow a similar path. Practitioners understandably want to protect their patients from psychic pain. However, quick fixes based only on a patient’s self-reporting can have tragic long-term consequences.
There are now a growing number of people who once self-identified as transgender but now have reversed or renounced their trans identity. Depending on their circumstances, these individuals are variously known as desisters, detransisitioners, or regretters.
Some are seeking accountability from the medical professionals who affirmed their wish to transition, without adequate assessment. An increasing number are speaking out on social media and at conferences, arguing they have been let down by mental-health services that failed to assess their psychological problems before prescribing medical treatments such as puberty blockers and cross-sex hormones, and referring them on for surgeries. Having initially felt welcomed in and encouraged by the trans community, these individuals often describe being ostracized by these same groups once they start to express doubts or questions regarding transition.
What follows are composite case studies known to the authors, both of whom are London-based psychotherapists. Names and identifying details have been omitted, anonymized, or otherwise altered so as to fully protect the identity of all concerned.
Case presentation # 1: “Bianca”
Bianca was a 25-year-old woman who came for an individual psychotherapy consultation in London, suffering from depression and anxiety. In the initial consultation, the therapist asked Bianca to talk about her history. Bianca said that she had had a mastectomy and hysterectomy when she was 20, after taking puberty blockers aged 16 then cross-sex hormones aged 18. She said she thought the whole thing was a mistake.
Bianca was the middle child of three. According to her description, the older brother was clever at school and her younger sister was very pretty and her mother’s favourite. She also described her parents having had a fiery relationship; her father gambled and was at times physically abusive. Eventually, he left the family home when Bianca was five years old, and Bianca’s mother became depressed and neglectful of the children. Bianca did not spend much time at home and joined her brother to play football at his local football club.
She was devastated when the teams were divided by sex and she had to join the female team, and she did not get on very well with her new teammates. Her school attendance became erratic, and following a letter from the school, she had several heated arguments with her mother. Following these arguments, she would go to stay with her father, who by this time had remarried and had young children by his second wife. Bianca said that she did not get on well with her stepmother, and would go back to her mother after arguments at her father’s home.
Bianca’s brother left the maternal home when he was 16, and Bianca described feeling completely isolated. She missed her brother, and her friendships faded with the boys at the football club, because by now they were more interested in girls who appeared more feminine. After eventually telling her mother about her feelings of hating her body and feeling she didn’t fit in with the other girls, it was suggested she was trans and that she should go to see her family doctor.
The therapist commented on how Bianca did not seem to feel she had a place in her parents’ world. Bianca said that she did not have any expectation that her parents would have tried to understand, as they had their own problems to deal with. Bianca started to research trans information online and contacted some of the websites and chat rooms she found.
Bianca: When I started my periods, I felt disgusted and started to hate my body and what I saw as my female sexual development.
Therapist: It sounds like you were trying to distance yourself from your feelings of pain and unhappiness, which seemed to get located in your body.
Bianca: [Starts to cry] I started to spend more and more time online, getting into trans websites. I just felt desperately lonely and I would make conversations on these groups about the fact that I did not feel as if I belonged anywhere. Back then, they seemed like the only friends I could rely on.
Bianca went on to say that she talked to her doctor about her depression and feelings of anxiety, but when she mentioned the gender dysphoria, the doctor immediately referred her on to the specialist gender service. Her online network had been happy when she told them the news. It was as if she had joined a club. Others started to share their own experiences with her and reassured her that now she would start to feel much better.
Therapist: As if they knew the solution to your feelings of unhappiness and detachment.
Bianca: Yes, it made me feel that I was really loved and belonged somewhere.
In the run-up to the gender-clinic appointment, Bianca’s online friends gave her lots of advice about the appointment: what to say and how to manage questions. She was seen by Britain’s specialist service for two assessment consultations in which she persuaded the worker that she had been gender dysphoric for many years and that she was feeling suicidal. Following this, she was placed on puberty blockers.
Bianca: After an initial feeling of excitement about starting on the blockers, I felt flat, as if all the life had been taken out of me. I spoke to the trans support group, and they said that it was normal and that I would feel better when I progressed onto the cross-sex hormones. Again, the group was incredibly supportive and encouraged me. I also started to experiment with living as a boy, and this gave me a feeling of excitement and pleasure. I began to drift away from all my friends, spending more and more time online in my chat group.
Therapist: You were being given an idea that everything would be okay if only you could stop your development as a girl and transition to be a boy.
Bianca: [Angrily] That was the message throughout the whole process, including some of the professionals who seemed to encourage the idea that transitioning was a solution to my problems. [After a pause] Looking back, I can see that the online group was always critical of my previous friends and family, encouraging me to feel that they did not understand me or that they were responsible for my feelings of rejection.
Therapist: As if the group talked directly to that part of you that always felt misunderstood and rejected. But the unhappy little girl who you wanted to be rid of still needed help and to be understood.
Discussion of the first consultation
It seems that Bianca’s parents had long-standing difficulties as a couple, which eventually led to their divorce, and it is likely her mother was preoccupied by her husband’s gambling and their marital arguments. One imagines this may have left Bianca feeling somewhat insecure and unable to match up to her sister’s looks or her brother’s intelligence. Bianca seemed to have a fraught relationship with her mother from the start, and the feeling of rejection was compounded as a teenager when she stayed with her father and his new family. She did not feel she belonged comfortably in either family.
Bianca did feel she discovered a place playing football, as she found it easy to identify with the boys and compete with them. This is in marked contrast to her relationship with her sister, with whom she felt a rivalry, perhaps because her sister was close to her mother, while Bianca did not feel close to either of them. Bianca was devastated when the teams divided into sexes.
Her therapist had the impression that she was a very unhappy little girl looking for a place where she could belong. Might the origin of her belief that she was a boy have taken root in the fantasy that she could leave behind this unhappy little girl by transitioning? Her physicality may have helped with her underlying feelings of sadness and increased her self-esteem.
We can see how Bianca feels that she is unlovable and unacceptable. She feels aggrieved toward her parents, who were preoccupied with their marital difficulties during her infancy and childhood. It may be that she developed a fantasy that she would have been loved if only she had been pretty and feminine like her sister; but if she cannot compete, she should get rid of any femininity.
The idea of transitioning seems to be connected to a wish to distance herself from underlying feelings of worthlessness and depression. This belief system shifts a further notch when she develops the idea that she would be better off as a boy. The exciting idea is that, whereas she feels like she is unloved and unlovable as a girl, she would be loved as a boy. The father seems to endorse this through his support for transition.
Bianca started by saying that she was very angry after the first meeting. She said that looking back she probably had doubts during the transition process, but the further she got into it, the more reluctant she was to stop and question what she was doing. She said that she just thought she felt so alone and the support of the online group was so important. Where would she belong if they rejected her?
Therapist: You were desperate to feel you belonged somewhere.
Bianca: I think my brother did question what I was doing. However, I dismissed him as being interfering, and the group said that he just did not understand. I have never really felt that I fit in, but I felt I was joining a group that was different from the rest of the world—a group that could see right through “normal” people and their narrow view of how things should be. After about six months, I went back to the clinic, and it was agreed I would start on the cross-sex hormones. When I told the group, they were delighted, saying that I was making great progress. Initially, I felt this surge of excitement. I felt powerful, and that this was the hit I had been looking for. I increased my social transition, as I started to feel like I was changing sex. I began to grow facial hair and gradually my voice got lower. Looking back, I can see that I had doubts, which I hid from everyone, including myself.
Therapist: The doubts would threaten to interfere with the powerful feeling of being in control.
Bianca: Yes. I thought, I don’t want to give them [doubters] any space. I had an argument with my brother, who by this time knew what was going on and started to argue with me, and asking, “What are you doing to yourself?” He told my mother, and she began to have a go at me. My mum and I had several terrible arguments in which I said to her that it was my body and my decision and that I knew what I wanted. My father, however, was much more accepting. He said that I must do whatever makes me comfortable. I don’t think he cared what I was doing, provided I didn’t cause any trouble for him and his new family. I started to think about going on a dating website and dating some girls. However, I was still looking like a girl and felt very self-conscious.
This was when I started to think I needed surgery. I began talking about this in my online group. I became convinced that I had to go through the whole thing—having my breasts removed then having the bottom surgery. I started researching and looking into the next steps. I met up with the trans community at organized events, and they were all so supportive and encouraging. I thought I had finally found somewhere I belonged. Once again, I was advised what to say in the interviews [with therapists and doctors]. It was like an exciting game.
Therapist: The group supported your belief that you could remove that unwanted girl.
Bianca: I thought with each step I could finally get rid of bad feelings—the cloud that hangs over my head. The rows with my mother increased over this time. She demanded to speak to the mental-health professional at the gender clinic. They told her that they couldn’t discuss my case with her because of my age, and that part of the reason for my distress was that she wouldn’t just support me. This made her furious, and she screamed and shouted at me, saying I was ruining myself just to get back at her, and my sister joined in saying that I am upsetting everyone in the family. My brother tried to be the go-between, but I accused him of siding with them.
All the time, my voice was getting lower and my male characteristics were becoming more obvious. Eventually, the rows got so bad at home that the police were called, and we were referred to social services. The social worker who assessed [my] family agreed to place me in separate accommodation. When I turned 18, I was transferred from child services to adult services and interviewed by a consultant to that service. I said that I had been living as a male for over a year and yet I still had an uncomfortable feeling of dysphoria. I said I wanted to have a mastectomy and some bottom surgery, as I thought this would make me feel better about who I was. After a brief interview with the consultant, he said he thought the operations would help me in my transition. He said that I should think about it, and that I would be seen for a follow-up in a month. At the second appointment, he agreed to put me on the waiting list for a “top surgery” [mastectomy] first, then once I had recovered from that we would discuss the various bottom-surgery options.
I had to wait several months for the first operation, during which time I started to get doubts about what I was doing. I mentioned my doubts to the [online] group, and they said that doubts were normal, [but] they would disappear when I had the mastectomy. They said that I had been unhappy as a girl for many years and that I probably wouldn’t be happy until I fully transitioned.
They were suspicious of newer members of the group, who expressed serious doubts about the process of transition. In many ways, the group got quite nasty, saying that the ones expressing doubts were weak and were selling out on their true selves. I remember feeling anxious about discussing my doubts anymore because I didn’t want to get that criticism from the group. By this time, I had left home and I was living on my own in a bedsit [one-room apartment], completely separated from my parents and everyone in my family, except for the odd phone conversation with my brother.
I went ahead with the operation and when I came around, I had dressings and drains and was still suffering the effects of the anaesthetic. The surgeon came to see me and said that the surgery was a complete success.
A couple of days later, I was discharged, but just before my discharge, a nurse came to change my dressing. When I looked at my scarred body, I collapsed into floods of tears. I got upset about seeing the wounds. Although they were neat, they were ugly cuts into my flesh. I couldn’t be discharged that afternoon because I felt so low. Eventually, I went back to my bedsit and, still feeling low, I started to think about what I had done to myself.
Therapist: You suddenly felt connected to the wounded body.
Bianca: After some time, I got a message from a friend. He asked what the matter was and said that it was perfectly normal to feel upset immediately after the surgery. He said that the anaesthetic was a depressant and took some time to get over. Then a couple of members of the [trans] group came to visit me and brought some drink and we had a bit of a party. [But] after a few days, I started to get the dysphoric feelings again, this time mixing in with my doubts about whether I had done the right thing. I talked again to my group online, [and they] all reassured me that this reaction was perfectly normal. They were also very critical of some members who were stalling their transition, as if they were letting the side down in some way and being cowardly.
After a couple of months, my mood started to lift again as the wounds healed, and I dressed in boys’ clothes. I felt excited about the fact that I was able to pass as a man. I even went on a couple of dates with women. But if they wanted to take things further, I realized that I would have to get undressed and then they would see my genitals and would know that I was biologically female. I thought this was an impasse that I couldn’t get over. One or two of the older and more vocal members in my online group said that I needed to go for the “bottom surgery,” which would help me feel more like a man. At this point, I had serious doubts about going forward, but it was almost as if I had come so far that I couldn’t stop now. In a way, there was no way back.
Therapist: To stop would mean losing the excitement of feeling you had found the solution, and instead to face what had been done.
Bianca: I felt depressed. I went to my doctor, and he gave me some antidepressants. They helped a bit, but I still felt as if I was depressed underneath. I already had a six-monthly follow-up appointment arranged. Avoiding any discussion of the doubts and the low mood I had experienced, I told the consultant that I was happy with the results of the operation and that I wanted to go ahead with the bottom surgery. Again, I had to wait, but there was very little real examination or questioning. The view seemed to be that most people who came through the process went on to be delighted with the results. I don’t really think I wanted to know about the negatives at any time.
I had six months of waiting with the usual doubts and feelings of worry about what I’d done to my body. I no longer listened so intently to the voices that said I needed to do more. I heard what they were saying, but I no longer believed them. However, I didn’t see any alternative to keeping going—I don’t really understand why.
Therapist: Very difficult for you to stop to face all these critical thoughts and feelings. I imagine you were worried you would be rejected by the group and you already felt you had lost connection with your family.
Bianca: Yes, but also, I feel angry now. Why didn’t anyone stop me or question me? Why didn’t anyone ask me, “Look, what are you doing?” Instead, they all endorsed it, encouraged it even. They all said that it would sort things out … The doctors should have asked more questions, delved a bit deeper.
Therapist: You wanted a professional to see what was driving you, [to] look behind your certainty, which was masking the hurt and rejection.
Bianca: [In tears] I am so angry with that bitch, and my father was useless. I was just under the influence of the group. It’s a bit like I was being brainwashed. They believe their nonsense about “everyone adjusts” and “it’s part of the journey.” Nobody really knows though, because once you’ve been operated on, no one follows you up. They check the physical wounds but then that’s it. After I’d had the hysterectomy, I had a consultation with the consultant. It was like everything had gone well and was a success and that was it. But there was no follow-up to see me in my depressed state.
Therapist: [It is] as if you no longer believed in the physical treatments as a cure for your difficulties … but there is so much to face if you stop—the painful question of what you have allowed to happen.
Bianca: I dropped out of the group. I knew the whole thing had been a mistake. I knew that I would be attacked, as others who doubted had been attacked. I just couldn’t face it. And far from thinking that I would be able to go out with a woman, I realized that any heterosexual woman would feel cheated by me as a man. I just looked odd, and I couldn’t bear to look at myself in the mirror.
A neighbour popped round to see me. He knew I was on my own after the surgery. An elderly man. He was so kind. He looked in and said, “Is everything all right? How did the operation go?” He had seen me from time to time over the years and I’d thought he must have noticed that I was changing and wondered what he thought of me. I imagined he was one of the “normal” people that the group looked down on. I burst into tears because I was struck by the fact that he had been watching, and had realized that I had been going through a difficult time and that I was not well. He was kind and took the trouble to come and see how I was.
Therapist: You felt ashamed and didn’t think anyone would take an interest in you, as if you didn’t deserve any care. I wonder if you hope that I will be somebody who is interested in you and that you are valued?
Bianca: [Sobbing] It was all too much then and I am not sure I can bear to think about it.
Therapist: You feel you need to understand what has gone on and to understand what part both you and others have played in this process.
Bianca: I want to try and understand it all—what’s gone wrong? I was just so miserable and didn’t feel loved. I didn’t listen to my brother and mother. I was just so angry with them and I didn’t think my mother had any right to tell me what to do. I just kept going with something so harmful. What a mess.
Discussion of the second consultation
Whenever Bianca expresses her doubts, the support group counters with the idea that full transition would provide a solution to her difficulties. Ordinary doubts and questions about this course of action are attacked and denounced as if thinking around the topic is a weakness (or even downright dangerous). Bianca adopts this position by pushing away conflicts and doubts.
Initially, Bianca describes the excitement involved in medical interventions. This seems to be related to the idea that she can triumph over her feelings of inadequacy and helplessness. However, over time the excitement wears off; and she starts to doubt the process. The difficulty is that she cannot face the possibility that she has been miserable about herself and the damage being inflicted on her. The doubts, which represent a sane concern that she is taking the wrong path, are dismissed as they threaten to take away the idea of transition as a cure. Giving up the idea of transition would leave Bianca with her underlying feelings of sadness, loneliness, and resentment. Hence, she pushes on to the next stage of treatment despite her misgivings. All the time, the trans group encourages her to go further in pursuing first hormonal, then surgical, interventions. Having felt she “belonged” and was accepted by the group, she cannot risk rejection from it.
We observe the way that the names given to the various interventions are changed so that the descriptions no longer represent a medical intervention with all the serious implications this involves. For example, testosterone is described as “T”; mastectomy is described as “top surgery”; metoidioplasty, vaginectomy, and hysterectomy as “bottom surgeries.” These euphemisms detach the intervention from its medical origins, perhaps in order to prevent painful associations. For example, mastectomies are commonly carried out on women who have a breast tumour—as such, it is a treatment designed to save a woman’s life. However, this is not the case with “top surgery,” as there is nothing physically wrong with the breasts. In Bianca’s case, the mastectomy is being undertaken in an attempt to deal with a psychological problem. It is the psyche’s concrete solution to a problem, given its inability to tolerate psychological pain through symbolic thinking.
Bianca is angry with the professionals who failed to examine the issues underlying her gender dysphoric presentation. She feels they all took a superficial and narrow gender-focused view of her difficulties. As with the use of abbreviated terms, it seems professionals are susceptible to taking an approach that cuts corners and avoids looking at underlying damage and pain.
Perhaps the initial assessment of Bianca and her difficulties may have lacked depth and substance, because it failed to understand that a vulnerable part of her, which needed recognition and support, was trapped within a defensive structure in her mind. Any failure by the services to recognize this clinical complexity represented an unwitting collusion with the fantasy that the vulnerable aspects of Bianca’s self and the pain of her dysphoria could be removed by physical interventions alone.
We are struck by the nature of the illusion that needed to be maintained by Bianca as she continued to go through the steps of transition. The illusion provided by the process of gender transition promises a way for Bianca to distance herself from being the unhappy and unwanted little girl she feels she carries around inside her. The promise was maintained by her and supported by others in the face of her doubts. For example, when first dating girls, Bianca can appear to be a man, but she can never sexually fully function as a man with a penis. When Bianca goes back to her support group with a doubt, they dismiss this and suggest the remedy is to pursue the transition further.
For Bianca at that point in her life, it appears easier to continue along a treatment path that offers her solutions, rather than face her doubts. In order for Bianca to do this alone, so much of the past would have to be faced, including the harm she may have done to herself by asking to transition. It would also require her to confront her own underlying feelings of depression, anger, and disappointment in her family and herself.
Bianca seemed to be looking for [a professional] who could identify the complexities of her clinical situation and who could maintain their own ideas in the face of her persistent beliefs, claims, and rigid certainty. She also needed somebody to help her with her feelings of anger, loneliness, and rejection. Instead, she felt the professionals all succumbed, and encouraged her in her thinking that she could change sex.
The final breakdown in her mental state occurs when she realizes that she still cannot actually change sex. She realizes that she had gone along with a medical belief that she could change from a “woman to a man.” Nevertheless, the social position of her gender does not change her biological sex.
Bianca was left to face the devastation on her own until the man in the flat next door noticed her pain. He seemed to represent a parental figure, who could see she felt unwell and was in need of care. She burst into tears because his comment touched on the very thing she had tried to keep out of her mind for so long.
In her therapy, Bianca was going to need quite a bit of help mourning the losses, both physical and emotional, [including] the new identity that she had believed she would become. The mourning process would involve a closer understanding of the patient’s feelings about the damage she had allowed to occur, while also acknowledging the damage done by others in their failure to care for her.
Case presentation # 2: “Emily”
Emily was a 22-year-old woman who had detransitioned and requested a psychotherapy consultation, because she wanted to understand what had driven her to transition in the first place. She started by telling the therapist about her earlier years. Emily was the eldest child, with two half-brothers on her father’s side and four half-brothers and one half-sister on her mother’s side. Her father had left home when she was very young, and her mother, who used to binge drink, had gone through tempestuous relationships with the fathers of Emily’s half-siblings. Emily had helped her mother raise the younger children, which meant she had grown up quickly.
The family moved often, usually due to problems paying rent or arguments with ex-partners and neighbours. The consequence was that Emily went to many different schools, which affected her academic work and presented her with problems fitting in to new peer groups. Her grandmother was the one stable figure in Emily’s life, and from time to time Emily stayed with her, an arrangement that she said she much preferred. However, her mother needed Emily to help with childcare, so she couldn’t stay with her grandmother permanently.
Emily felt the odd one out from the girls at school, who she thought were somehow prettier and cleverer than her, while the boys didn’t allow her to join in with their games. She recalled that she had gone through a stage of school refusal, and felt very down and lonely when she was about nine years old. During this time, there was an assessment of her home conditions, and she was put on the social-services register. What she never told the services was that the stepfather of her youngest brother would touch her inappropriately when nobody else was looking. She managed the situation by trying to absent herself when he was around.
Emily remembered falling in love with a girl at 14 years of age, and being extremely worried that her grandmother would disapprove, as she was a devout Christian and had strong views on homosexuality. Emily eventually said something to the friend but was rejected because the girl said that she was “not a les [i.e., lesbian].”
Emily said that she remembered cutting her arms whenever she spent time thinking about this girl. She remembers feeling unhappy and suicidal, and the family doctor prescribed her antidepressants. During this time, she spent a lot of time online, and she found several websites where people blogged about being trans. This led her on to watching videos of the journeys of females who were transitioning, and she started to believe that she was “one of them.” Emily showed an article about female-to-male transition to her mother, who responded by asking her if she wanted to have her breasts removed. Initially, she thought she did not, as she was not dysphoric about them, but then she thought that it might be a good idea. Her rationale for this was that she remembered thinking that she did not want to have any children in the future, and therefore would have no need of breasts.
Emily said that she started to tell herself that she did not really like her body, in order to fit in more with the other online friends and their descriptions of “being trans.” Despite not feeling particularly dysphoric, Emily started to wear a binder for her breasts and eventually reached the stage where she would not leave the house without the binder on. She found it extremely uncomfortable, but said that she could remember feeling there was almost something good about being able to withstand the pain, as if it were an achievement of some sort.
Over time, she spent more and more hours on Internet chat rooms, where she felt persuaded to go on to transition, and at 16 she asked her local doctor to refer her to the gender-identity clinic. Once referred, she persuaded clinic staff that she wanted to transition. She commenced on cross-sex hormones aged 17.
Emily explained that she did not really engage with thoughts about why she wanted to transition, or what the long-term implications would be. She explained to the clinic that she hated herself and hated her love of women, which she felt was unacceptable. She described living in a dream-like state, supported by her trans friends online, who encouraged her to believe that she would feel so much better when she had transitioned. At no stage did anyone explain that she could not biologically transition to be a male:
I was in a state of mind where I always imagined that the solution to my self-hatred and my insecurity as a woman would be cured by my transition in the future. Any obstacle or delay in the process caused me enormous frustration and anxiety. It felt as if people were deliberately making me miserable and refusing to help me. Any time I felt unhappy, depressed, or anxious about myself I would think it’s because I hadn’t gone far enough along the process to transition, and that I needed to press ahead to the next stage. I was riddled with doubts about my looks and completely preoccupied with how people saw me. It was very difficult to think about anything else. It was as if my whole life [had been] taken over by a preoccupation with whether I passed as a man or not. I was completely self-absorbed.
When I reached 20 years of age, I was having ongoing cross-sex hormones and constantly worried that I would be somehow found out or exposed. I realized that the “T” injections were a reminder that I needed the hormones to continue the changes in my body, but I would never feel confident that I passed as a man. I also realized that I would never actually be a man. Ridiculously, I think I had convinced myself that I could change biological sex.
I felt ashamed of the fact that I had sustained such a stupid idea for such a long time. It made me feel foolish and I became a bit depressed. Eventually, I decided that I didn’t want to spend the rest of my life acting a part and constantly feeling like a fraud. It was then that I decided to detransition. Once I had made that decision, I overcame my feeling of embarrassment and anxiety, and asked my mum and then my family doctor to help me detransition.
Emily described a chaotic family situation in which she plays the role of a “parentified” child who supported her mother in caring for half-siblings. She didn’t feel like she could measure up against other girls, and the therapist suspected that this was related to problems she’d had internalizing a good object [a Freudian term that describes an internal representation of a significant figure in one’s life]. The therapist hypothesized that Emily’s mother was likely to have been preoccupied by the tempestuous nature of her adult relationships, and this might have affected her capacity to bond with her daughter. This in turn would have affected Emily’s future confidence in relation to her peers.
There isn’t a straightforward relationship between early traumas and later psychological or relational difficulties. However, studies show that early trauma is a contributing factor in causing ongoing problems in relation to the self and relationships in the external world. Emily’s description of her childhood presented a picture of a rather deprived, unhappy, insecure little girl who did not have a good internal sense of herself.
Emily’s grandmother is the one stable influence in her life, and she recognizes this relationship’s value as she tries to fit in with her grandmother’s strict religious values in order to protect and sustain it. This meant that her loving feelings toward other girls are unacceptable to her. The idea of transitioning seems to offer a solution to her dilemma. In fantasy, it also might represent the opportunity to get rid of the unhappy, unacceptable little girl inside her and replace her with a happier “male” self. She also likely felt resentful that she did not get the love and attention she needed from her own mother. When she contemplates the removal of her breasts, she is perhaps getting rid of something that represents soft, maternal feelings. It is hard for her to imagine she could become a mother of other children who would need both breastfeeding and loving care when she has felt so deprived of this herself.
Likewise, she has resented having to care for the half-siblings who steal her mother’s attention, and perhaps cannot envisage herself as an adult who could give generously to another child. We can understand how she might have wanted to get away from the feminine role that she felt leaves her exposed to painful feelings of being unwanted and rejected. Emily also seems to feel that she did not “make the grade” as a woman at school in terms of her attractiveness or in terms of her schoolwork.
The collapse of her belief in transitioning is related to Emily’s realization that she has been seduced by an illusory solution that she could actually change biological sex. The constant persecution of having to “pass” represents a reminder somewhere in her mind that she is not a man.
“Passing” as a man allows the illusion that she can change sex to be temporarily maintained. The exhausting nature of the way in which she surveys others’ reaction to her, and her own doubts and misgivings about how she is perceived by others and herself, eventually leads to a breakdown. This clinical example of how taxing it can be for a trans-identified person to maintain control over their own and others’ perceptions helps us to understand the sensitivity and the traumatic experience of being misgendered by others.
Detransitioners and desisters often report being aware of doubts in their minds, but then ignoring them and pushing on. This involves a form of mental double bookkeeping as, on the one hand they push for transition, while on the other hand they question the direction of travel.
We have observed that the desire to transition is often connected to an attempt to distance the person from the psychic pain related to internal and/or external traumatic experiences. These traumas and their effects can be reawakened by more recent developmental conflicts or events in the young person’s life. The child tries to control their underlying vulnerability by projecting unwanted aspects of the self into their natal body, which is then regarded as the problem that needs to be changed or eradicated. At this point in their gender-identity history, most young people will strongly resist any attempts to explore the psychological aspects of their presentation because they will feel any adult who questions their resolution is undermining their solution to their psychological well-being.
In our clinical experience, we often find that the vulnerable part of the self, which is hated, has been captured by a part of the self that believes psychic pain can be eradicated through a transition. Ordinary doubts and anxieties about the belief system are dismissed and attacked as they undermine the concrete solution. However, once the excitement of transition wears off, the individual can find themselves disillusioned, facing the social, physical, and psychological damage done. This can lead to a re-emergence of underlying feelings of despair, sadness, and anger, now often compounded by a sense of guilt or shame for their own part in the process.
Patients who self-harm or take overdoses after medical and/or surgical gender transition treatments often report to emergency services in crisis. A common theme in their presentations is a belief that physical treatments would remove or resolve aspects of themselves that caused them psychic pain. When the medical intervention fails to remove these psychological problems, the disappointment and often anger lead to an escalation of self-harm and suicidal ideation, as resentment and hatred toward themselves is acted out on their bodies.
Detransitioners and desisters can also feel angry at psychiatric and medical specialists, who they understandably believe have not adequately assessed their motivations for requesting medical intervention. Grievances toward parental figures in the past can be reactivated and directed towards these authority figures, who are perceived to have failed in their duty of care. In the cases of Emily and Bianca, early experiences of neglect are re-enacted, leaving them feeling that the traumas of the past are being re-enacted in the present.
Susan Evans tweets at @sueevansprotect. She is a psychoanalytic psychotherapist, a former registered nurse and psychiatric nurse, and a former staff member of Britain’s public-health Gender Identity Development Service. Marcus Evans tweets at @marcusevanspsyc. He is a psychoanalyst in private practice, and formerly served as Consultant Psychotherapist and Associate Clinical Director of Adult and Adolescent Service at the Tavistock and Portman NHS Trust. This essay has been adapted, with the authors’ permission, from the recently published book, Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults, by Susan Evans and Marcus Evans, published by Phoenix Publishing House Ltd. Copyright © 2021 by Susan Evans and Marcus Evans.
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