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Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults
In recent years, there has been an explosion in the number of children and young people who diagnose themselves as gender dysphoric, or trans. In the UK, and worldwide, there is a growing tendency to refer them on to 'specialist gender services' almost as soon as they express any confusion or distress about their biological sex or gender identity. Due to the rapidly rising numbers and various pressures on the system, patients are increasingly likely to be offered life-altering medication and/or surgical treatments, often with little exploration of their emotional world.
As so little is yet known or understood regarding this increase in gender incongruent patients, it seems precipitous to proceed onto physical treatments before any assessment work is undertaken. Many who present as gender dysphoric have complex needs with comorbid problems such as autism, histories of abuse or trauma, social phobias, depression, eating disorders, and other mental health symptoms. Therefore, all aspects of the individual's life deserve thorough assessment and therapeutic work.
This book is aimed primarily at clinicians working in the field to provide a model for understanding, assessing, and treating gender dysphoria. The model uses a psychoanalytic framework to help explain disturbed states of mind and how psychic defences can be enlisted unconsciously to avoid overwhelming psychic pain. This offers professionals a way of trying to think with, and offer understanding to, their trans identifying clients. Clinical examples are given to illustrate these processes and promote the understanding of transgender children, adolescents, and young people and their internal worlds, their thinking, and their interpersonal relationships. As well as clinical exploration and understanding, the book includes an overview of the current political, social, and clinical environments which have all impacted on the clinical care of trans identifying individuals.
As well as professional and trainee clinicians, this book might also prove useful to parents, other professionals, and possibly the gender dysphoric person too.
As so little is yet known or understood regarding this increase in gender incongruent patients, it seems precipitous to proceed onto physical treatments before any assessment work is undertaken. Many who present as gender dysphoric have complex needs with comorbid problems such as autism, histories of abuse or trauma, social phobias, depression, eating disorders, and other mental health symptoms. Therefore, all aspects of the individual's life deserve thorough assessment and therapeutic work.
This book is aimed primarily at clinicians working in the field to provide a model for understanding, assessing, and treating gender dysphoria. The model uses a psychoanalytic framework to help explain disturbed states of mind and how psychic defences can be enlisted unconsciously to avoid overwhelming psychic pain. This offers professionals a way of trying to think with, and offer understanding to, their trans identifying clients. Clinical examples are given to illustrate these processes and promote the understanding of transgender children, adolescents, and young people and their internal worlds, their thinking, and their interpersonal relationships. As well as clinical exploration and understanding, the book includes an overview of the current political, social, and clinical environments which have all impacted on the clinical care of trans identifying individuals.
As well as professional and trainee clinicians, this book might also prove useful to parents, other professionals, and possibly the gender dysphoric person too.
288 pages, Paperback
First published January 1, 2021
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June 29, 2021
“The lack of a psychological model for thinking about gender dysphoria has hampered clinicians working with this group of patients. We believe that psychodynamic psychotherapy offers a model for thinking about fixed states of mind. It also offers a model for thinking about how individuals create split states of mind in which something can be acknowledged and accepted on the one hand, while being denied on the other. The theory of projection allows us to consider ways in which unwanted aspects of the self are denied and split off into others, as well as the unconscious clues these provide when these issues are repeated in the transference and countertransference. Whatever the outcome of a person’s wish to transition, they should be offered extended assessment and exploratory therapeutic work before any medical treatment is commenced. Even when an individual goes on to have medical treatments, this therapeutic work will help prepare them for life after the medical intervention. Gender transition is not an easy road to take and many members of the trans community have ongoing mental health problems, with many experiencing continuing symptoms of gender dysphoria despite medication and surgery.” [p201]
In this passage, the authors summarise the main objectives of this book and I will use it below to structure my review.
“Gender transition is not an easy road to take…” The physical and mental toll of gender transition, regardless of outcome, is huge for the individual involved. This calls for a corresponding degree of empathy and concern from those involved in their care.
“…and many members of the trans community have ongoing mental health problems, with many experiencing continuing symptoms of gender dysphoria despite medication and surgery.” There is an ongoing and rather politicised discussion about whether gender dysphoria should be considered a mental illness in itself. This may not make much difference. As a matter of practical experience, the authors point that that the young people referred to them for therapy typically did have ongoing mental health problems that justified clinical attention and concern, regardless of gender identity questions, and that even the seemingly successful completion of medical transition did not of itself reduce them, contrary to claims that are often made. Even if gender dysphoria is not labelled as a mental illness, it is worth investigating what lies behind it, because it is – in practice – common to find that it is a symptom of an underlying problem. In any case, the resolution of related mental health problems can only be beneficial to the individual confronting the already intimidating process of transition. Hence: “Whatever the outcome of a person’s wish to transition, they should be offered an extended assessment and exploratory therapeutic work before any medical treatment is commenced. Even when an individual goes on to have medical treatments, this therapeutic work will help prepare them for life after the medical intervention.”
” The lack of a psychological model for thinking about gender dysphoria has hampered clinicians working with this group of patients.” The authors do not discuss transgender medicine directly, let alone its history, but it is worth clarifying that it usually proceeds on the basis of an entirely medical model: concrete, physical interventions that claim to “align” the body more closely to the “gender identity” of the patient. Such a medical model can and often does operate without a formally articulated psychological theory to explain or justify its procedures and outcomes, let alone to permit critical evaluation. When pushed, its practitioners will often rely on a highly Positivist understanding of the nature of science and this may be reflected in hostility to the work of psychotherapists, referring for example to the extensive debunking of Freud’s theories about the human mind. The salient point here is that there is a history of professional as well as ideological rivalry in advocating different approaches to this ( and any other) aspect of the human condition [and indeed this rivalry has underpinned the ideas of Foucault among many others]. In transgender medicine, psychological theory has always been secondary to the practical medical interventions.
Even within the field of psychotherapy itself, there are a range of competing theories and practices, with differences often expressed in heated terms. One significant and relevant aspect of this debate (which the authors only hint at) is the history of malpractice and plain bad science across the entire field, driven both by the need for status among academics and practitioners and by profit and greed among individuals and corporations. Classic examples tend to be the practice of lobotomy, excessive use of electroconvulsive therapy and debunked treatments for nonconforming women or for homosexuals. There are important issues here about public trust and medical ethics, and the need for proper regulation remains a very open debate, with the courts playing a key role in filling regulatory gaps.
The authors negotiate this ideological minefield with care and precision. Their objective is very specific and limited and they do not become distracted by the wilderness beyond their boundaries. Their primary political manifesto is an anti-political one: ” Young people need an independent clinical service that has the long-term interests of the patient at heart. To some extent, this requires a capacity to stand up to pressure coming from various sources: from the young person, their family, peer groups, from online / social networking pressures and of course from highly politicised pro-trans groups. [p213] Adherents of Foucault would not be alone in noticing that this risks becoming a rather typical plea from a professional group to evade scrutiny but there is a big difference between public, academic or professional scrutiny and debate over medical and psychological theories and practice on the one hand and, on the other hand, the ability of therapists to work conscientiously and ethically with each individual client, protected from external interference (though not at all without accountability). In any event, that type of criticism is addressed in the authors’ appeal for “gold standard” clinical evidence to support any practice:
“The rapidly expanding and poorly understood area of gender dysphoria in young people requires new approaches and a model to ensure a more clinically rigorous, balanced and ethical treatment for this complex area. … We are not saying our model is the only one to consider and we are sure we have not covered everything. What we reiterate is that treatments for people experiencing gender dysphoria need to be evidence based on long term, high standard research studies and provide an independent and thorough examination of all treatment outcomes. The ordinary ethical standards of good practice need to be restored to this clinical area because our first duty is to “do no harm.”” [p234]
Both of the authors have extensive practical experience of providing psychotherapy for children and young adults with gender dysphoria. It is useful to consider what is the evidence they bring to this discussion. It is organisational (perhaps this really is political), clinical and theoretical.
For the first, they both participated for a good many years as members of a multi-discipline team working with gender dysphoric patients at the Tavistock clinic in London, which is contracted to the NHS to provide a specialist GIDS service for England and Wales and also for Ireland. They have therefore worked closely with professionals of other disciplines and are deeply familiar with the way gender dysphoria and gender identity generally is addressed in the UK and internationally. They both expressed growing concerns at practices in the Tavistock service, followed whistle blowing procedures, contributed to political discussion of the issues and played key roles in the eventual judicial review in which Keira Bell and another party won a ruling that children lack the capacity to give informed consent to medical interventions with gender identity, that have lasting, irreversible and harmful consequences. In effect, that ruling overthrows the validity of the current commitment to affirmation and medical transition as the standard if not the only response to gender dysphoria. By the same token, it established the urgent need for alternative treatment options, which this book seeks to address.
The book’s clinical evidence is based on a series of case studies, chosen as exemplars for important themes or issues in the treatment process. This type of evidence has a valid place in medical science subject to intrinsic limitations which are also well understood. Whatever it does not achieve (nor claim to) it has important results which cannot be readily ignored. For example, in the reports of young adults who have been through the transition process and return for further support, it is essential to attend to criticisms they make about their experience of care and advice through the process. (Of course, Keira Bell provided this type of evidence to the High Court with significant impact.) It is qualitative evidence and not quantitative but sometimes, for example, one requires such qualitative investigations before it is possible to go on to a meaningful quantitative study; the different approaches are complementary, not mutually exclusive. It would be good, for example, to establish statistically how representative Keira Bell’s experiences really are, but that requires the type of research that has not yet been attempted and that frankly ought to have been by now.
Case studies certainly make up the most valuable and engaging part of this book. We encounter children who are initially quite fixed and confident in their demand for medical transition, and witness a process by which their motivations and their expectations are quietly explored and, in many cases (but not all), the child is enabled to emerge from that rigid state of mind with a more healthy and accepting approach to their choices. More importantly we see how easy and how destructive it would be to simply accept their demands at face value, provide the medical intervention they demand, only to find that the opportunity to address their emotional needs has been wasted.
It is interesting too that the case studies typically incorporate meetings with and sometimes additional therapy for parents of the dysphoric child. One of the major arguments in the Keira Bell appeal (not discussed in the book) is the suddenly discovered importance of parents in securing consent for the medication of children. Up to now, parents have more usually been seen as the enemy. This book illustrated clearly that parental consent has its own significant difficulties and challenges and cannot just be accepted on face value. The dysphoric child is often part of a family that is itself dysfunctional in important ways. In fact, this is something that is probably well known but not given the attention it would require if parental consent became central to medical decision making.
Finally, the book’s theoretical evidence may cause friction, because it is squarely based on a psychoanalytic model and the world and her mother have now read Why Freud Was Wrong (as of course he was). Stephen Levine contributed an excellent Forward in which he reminds us that “One must not confuse formal psychoanalysis with what is described here… Studies have indicated that therapist ideology is less important in creating a positive short-term outcome than the quality of connection to the patient. Warmth, caring, absence of hostility. And grasp of what the patient is feeling and saying seems to predispose to better outcomes. Insight is vital. (Hogland, 2018)” [pxxvi] This is fair enough but misses the point that the authors are indeed proposing their psychodynamic, therapeutic model for work with gender dysphoric children and indeed for older age groups too. They think their “ideology” is important and they explain what is important in the quote I have relied on throughout this review: “We believe that psychodynamic psychotherapy offers a model for thinking about fixed states of mind. …a model for thinking about how individuals create split states of mind…. The theory of projection allows us to consider ways in which unwanted aspects of the self are denied and split off into others, as well as the unconscious clues these provide when these issues are repeated in the transference and countertransference.”
This is not necessarily a model for life as we know it, it is a model for the way therapy might be conducted, a toolkit of important techniques using practical concepts of fixed states of mind, split states of minds, projection, transference, countertransference. Indeed, the theoretical chapters late in the book greatly expand this list. I would select out countertransference and supervision as especially significant. Without being technical, the role of supervision is to help / remind a therapist to monitor closely their own feelings and thoughts in response to the patient, because these can become a source of useful information about what is happening in therapy for the patient. At times, the patient hands to the therapist responsibility for “containing” and working with powerful emotions that the patient is unable to tolerate or handle alone. The temptation is to spare the patient (and hence the therapist) from distress by simply refusing to do that work. A weak therapist will simply take the patient at their word, agree to their requests, avoid conflict and probably earn a very friendly and grateful response, having spared everyone a lot of angst. In reality, therapy is only rewarding and beneficial if the therapist and the patient do find ways to handle the distress and tackle the problems they encounter. The role of the therapist is very demanding and the therapist can only fulfil this role effectively with the support of an experienced supervisor who is, in turn, prepared to be actively critical, not collaborate in just going through the motions. I have some experience of training in psychotherapy and I would say that the self discipline required of therapists and supervisors is hard to achieve; this is why therapist in practice are so variable and finding the good ones is not always easy.
It is not necessary for the authors to enter into an extended critique of the affirmation and medical intervention model which they have clearly rejected. In reading through their case studies and their theoretical material, it is increasingly obvious that the model of affirmation and medical intervention is deeply flawed. What Susan and Marcus Evans have achieved is to demonstrate a coherent model for therapy, spell out the specific challenges that must be met and invite others to either use and perhaps improve upon their model or demonstrate an alternative that can meet the same goals.
Quotes
“For instance, the patient might act almost as a customer who has been sold the wrong body and is outraged at the reluctance of the shop to give them a new one. In this way a complex psychological configuration in the mind is treated as if it were a concrete problem located in the body.” [p212]
Staff working with children who are suffering from gender dysphoria obviously want to protect them from unnecessary pain and anxiety. However, pain and anxiety often provide an indication of an underlying problem that needs attention, and we believe this is the case with gender dysphoria…. The current transgender treatment has physical and mental long-term costs in terms of loss of sexual functioning and a lifelong need for medical interventions. Therefore, a thorough assessment of the underlying issues is critical, particularly in relation to young people. [p217]
Medicine also gets into trouble when its motive and raison d’etre shifts from treating illness into providing ideal solutions to the problems of life. These promised solutions often come with hidden, unseen costs based on a belief that the facts of life can be overcome or ignored when they need to be accepted and faced. [P217]
…if the individual has no concern at all about the prospect and outcomes of medical intervention, this lack of concern should be thought of as a symptom that needs to be investigated, rather than simply a positive indication of the patient’s motivation. [p223]
For example, if the young person wants to change their name from Joanne to John, the therapist should keep in mind what Joanne represents and why she is felt to be so unwanted or disliked. The little girl Joanne has existed thus far and is important, so her body and identity need to be considered and kept in mind. Attempts to eradicate unwanted aspects of the self are universally employed by all humans, but it is not really possible… [p228]
A negative therapeutic reaction can sometimes lead to a disruption or even a premature end of the therapy. However, accounts from detransitioners sometimes evidence that it can be that in these dramatic episodes “a seed is sown” and this allows an ongoing positive therapeutic effect… [p229]
John Steiner, in a paper entitled “Time and the Garden of Eden Illusion” (2018), describes a phantasy of the individual returning to an illusory ideal relationship with the mother. This is often connected with an ideal time, place or relationship in the patient’s life before things went wrong. [p230]
You can do surgery on the body but it is mistaken to try to surgically remove a part of the personality. Psychological maturity and mental health are based on an ability to tolerate different aspects of the personality and intolerance does not help psychic integration. As part of the assessment consultation, it is helpful to try to understand what problems the patient had with their given name and what aspects of their personality they were wanting to try to get rid of by transitioning and what ideas they have of whom they are going to become. [p230]
In this passage, the authors summarise the main objectives of this book and I will use it below to structure my review.
“Gender transition is not an easy road to take…” The physical and mental toll of gender transition, regardless of outcome, is huge for the individual involved. This calls for a corresponding degree of empathy and concern from those involved in their care.
“…and many members of the trans community have ongoing mental health problems, with many experiencing continuing symptoms of gender dysphoria despite medication and surgery.” There is an ongoing and rather politicised discussion about whether gender dysphoria should be considered a mental illness in itself. This may not make much difference. As a matter of practical experience, the authors point that that the young people referred to them for therapy typically did have ongoing mental health problems that justified clinical attention and concern, regardless of gender identity questions, and that even the seemingly successful completion of medical transition did not of itself reduce them, contrary to claims that are often made. Even if gender dysphoria is not labelled as a mental illness, it is worth investigating what lies behind it, because it is – in practice – common to find that it is a symptom of an underlying problem. In any case, the resolution of related mental health problems can only be beneficial to the individual confronting the already intimidating process of transition. Hence: “Whatever the outcome of a person’s wish to transition, they should be offered an extended assessment and exploratory therapeutic work before any medical treatment is commenced. Even when an individual goes on to have medical treatments, this therapeutic work will help prepare them for life after the medical intervention.”
” The lack of a psychological model for thinking about gender dysphoria has hampered clinicians working with this group of patients.” The authors do not discuss transgender medicine directly, let alone its history, but it is worth clarifying that it usually proceeds on the basis of an entirely medical model: concrete, physical interventions that claim to “align” the body more closely to the “gender identity” of the patient. Such a medical model can and often does operate without a formally articulated psychological theory to explain or justify its procedures and outcomes, let alone to permit critical evaluation. When pushed, its practitioners will often rely on a highly Positivist understanding of the nature of science and this may be reflected in hostility to the work of psychotherapists, referring for example to the extensive debunking of Freud’s theories about the human mind. The salient point here is that there is a history of professional as well as ideological rivalry in advocating different approaches to this ( and any other) aspect of the human condition [and indeed this rivalry has underpinned the ideas of Foucault among many others]. In transgender medicine, psychological theory has always been secondary to the practical medical interventions.
Even within the field of psychotherapy itself, there are a range of competing theories and practices, with differences often expressed in heated terms. One significant and relevant aspect of this debate (which the authors only hint at) is the history of malpractice and plain bad science across the entire field, driven both by the need for status among academics and practitioners and by profit and greed among individuals and corporations. Classic examples tend to be the practice of lobotomy, excessive use of electroconvulsive therapy and debunked treatments for nonconforming women or for homosexuals. There are important issues here about public trust and medical ethics, and the need for proper regulation remains a very open debate, with the courts playing a key role in filling regulatory gaps.
The authors negotiate this ideological minefield with care and precision. Their objective is very specific and limited and they do not become distracted by the wilderness beyond their boundaries. Their primary political manifesto is an anti-political one: ” Young people need an independent clinical service that has the long-term interests of the patient at heart. To some extent, this requires a capacity to stand up to pressure coming from various sources: from the young person, their family, peer groups, from online / social networking pressures and of course from highly politicised pro-trans groups. [p213] Adherents of Foucault would not be alone in noticing that this risks becoming a rather typical plea from a professional group to evade scrutiny but there is a big difference between public, academic or professional scrutiny and debate over medical and psychological theories and practice on the one hand and, on the other hand, the ability of therapists to work conscientiously and ethically with each individual client, protected from external interference (though not at all without accountability). In any event, that type of criticism is addressed in the authors’ appeal for “gold standard” clinical evidence to support any practice:
“The rapidly expanding and poorly understood area of gender dysphoria in young people requires new approaches and a model to ensure a more clinically rigorous, balanced and ethical treatment for this complex area. … We are not saying our model is the only one to consider and we are sure we have not covered everything. What we reiterate is that treatments for people experiencing gender dysphoria need to be evidence based on long term, high standard research studies and provide an independent and thorough examination of all treatment outcomes. The ordinary ethical standards of good practice need to be restored to this clinical area because our first duty is to “do no harm.”” [p234]
Both of the authors have extensive practical experience of providing psychotherapy for children and young adults with gender dysphoria. It is useful to consider what is the evidence they bring to this discussion. It is organisational (perhaps this really is political), clinical and theoretical.
For the first, they both participated for a good many years as members of a multi-discipline team working with gender dysphoric patients at the Tavistock clinic in London, which is contracted to the NHS to provide a specialist GIDS service for England and Wales and also for Ireland. They have therefore worked closely with professionals of other disciplines and are deeply familiar with the way gender dysphoria and gender identity generally is addressed in the UK and internationally. They both expressed growing concerns at practices in the Tavistock service, followed whistle blowing procedures, contributed to political discussion of the issues and played key roles in the eventual judicial review in which Keira Bell and another party won a ruling that children lack the capacity to give informed consent to medical interventions with gender identity, that have lasting, irreversible and harmful consequences. In effect, that ruling overthrows the validity of the current commitment to affirmation and medical transition as the standard if not the only response to gender dysphoria. By the same token, it established the urgent need for alternative treatment options, which this book seeks to address.
The book’s clinical evidence is based on a series of case studies, chosen as exemplars for important themes or issues in the treatment process. This type of evidence has a valid place in medical science subject to intrinsic limitations which are also well understood. Whatever it does not achieve (nor claim to) it has important results which cannot be readily ignored. For example, in the reports of young adults who have been through the transition process and return for further support, it is essential to attend to criticisms they make about their experience of care and advice through the process. (Of course, Keira Bell provided this type of evidence to the High Court with significant impact.) It is qualitative evidence and not quantitative but sometimes, for example, one requires such qualitative investigations before it is possible to go on to a meaningful quantitative study; the different approaches are complementary, not mutually exclusive. It would be good, for example, to establish statistically how representative Keira Bell’s experiences really are, but that requires the type of research that has not yet been attempted and that frankly ought to have been by now.
Case studies certainly make up the most valuable and engaging part of this book. We encounter children who are initially quite fixed and confident in their demand for medical transition, and witness a process by which their motivations and their expectations are quietly explored and, in many cases (but not all), the child is enabled to emerge from that rigid state of mind with a more healthy and accepting approach to their choices. More importantly we see how easy and how destructive it would be to simply accept their demands at face value, provide the medical intervention they demand, only to find that the opportunity to address their emotional needs has been wasted.
It is interesting too that the case studies typically incorporate meetings with and sometimes additional therapy for parents of the dysphoric child. One of the major arguments in the Keira Bell appeal (not discussed in the book) is the suddenly discovered importance of parents in securing consent for the medication of children. Up to now, parents have more usually been seen as the enemy. This book illustrated clearly that parental consent has its own significant difficulties and challenges and cannot just be accepted on face value. The dysphoric child is often part of a family that is itself dysfunctional in important ways. In fact, this is something that is probably well known but not given the attention it would require if parental consent became central to medical decision making.
Finally, the book’s theoretical evidence may cause friction, because it is squarely based on a psychoanalytic model and the world and her mother have now read Why Freud Was Wrong (as of course he was). Stephen Levine contributed an excellent Forward in which he reminds us that “One must not confuse formal psychoanalysis with what is described here… Studies have indicated that therapist ideology is less important in creating a positive short-term outcome than the quality of connection to the patient. Warmth, caring, absence of hostility. And grasp of what the patient is feeling and saying seems to predispose to better outcomes. Insight is vital. (Hogland, 2018)” [pxxvi] This is fair enough but misses the point that the authors are indeed proposing their psychodynamic, therapeutic model for work with gender dysphoric children and indeed for older age groups too. They think their “ideology” is important and they explain what is important in the quote I have relied on throughout this review: “We believe that psychodynamic psychotherapy offers a model for thinking about fixed states of mind. …a model for thinking about how individuals create split states of mind…. The theory of projection allows us to consider ways in which unwanted aspects of the self are denied and split off into others, as well as the unconscious clues these provide when these issues are repeated in the transference and countertransference.”
This is not necessarily a model for life as we know it, it is a model for the way therapy might be conducted, a toolkit of important techniques using practical concepts of fixed states of mind, split states of minds, projection, transference, countertransference. Indeed, the theoretical chapters late in the book greatly expand this list. I would select out countertransference and supervision as especially significant. Without being technical, the role of supervision is to help / remind a therapist to monitor closely their own feelings and thoughts in response to the patient, because these can become a source of useful information about what is happening in therapy for the patient. At times, the patient hands to the therapist responsibility for “containing” and working with powerful emotions that the patient is unable to tolerate or handle alone. The temptation is to spare the patient (and hence the therapist) from distress by simply refusing to do that work. A weak therapist will simply take the patient at their word, agree to their requests, avoid conflict and probably earn a very friendly and grateful response, having spared everyone a lot of angst. In reality, therapy is only rewarding and beneficial if the therapist and the patient do find ways to handle the distress and tackle the problems they encounter. The role of the therapist is very demanding and the therapist can only fulfil this role effectively with the support of an experienced supervisor who is, in turn, prepared to be actively critical, not collaborate in just going through the motions. I have some experience of training in psychotherapy and I would say that the self discipline required of therapists and supervisors is hard to achieve; this is why therapist in practice are so variable and finding the good ones is not always easy.
It is not necessary for the authors to enter into an extended critique of the affirmation and medical intervention model which they have clearly rejected. In reading through their case studies and their theoretical material, it is increasingly obvious that the model of affirmation and medical intervention is deeply flawed. What Susan and Marcus Evans have achieved is to demonstrate a coherent model for therapy, spell out the specific challenges that must be met and invite others to either use and perhaps improve upon their model or demonstrate an alternative that can meet the same goals.
Quotes
“For instance, the patient might act almost as a customer who has been sold the wrong body and is outraged at the reluctance of the shop to give them a new one. In this way a complex psychological configuration in the mind is treated as if it were a concrete problem located in the body.” [p212]
Staff working with children who are suffering from gender dysphoria obviously want to protect them from unnecessary pain and anxiety. However, pain and anxiety often provide an indication of an underlying problem that needs attention, and we believe this is the case with gender dysphoria…. The current transgender treatment has physical and mental long-term costs in terms of loss of sexual functioning and a lifelong need for medical interventions. Therefore, a thorough assessment of the underlying issues is critical, particularly in relation to young people. [p217]
Medicine also gets into trouble when its motive and raison d’etre shifts from treating illness into providing ideal solutions to the problems of life. These promised solutions often come with hidden, unseen costs based on a belief that the facts of life can be overcome or ignored when they need to be accepted and faced. [P217]
…if the individual has no concern at all about the prospect and outcomes of medical intervention, this lack of concern should be thought of as a symptom that needs to be investigated, rather than simply a positive indication of the patient’s motivation. [p223]
For example, if the young person wants to change their name from Joanne to John, the therapist should keep in mind what Joanne represents and why she is felt to be so unwanted or disliked. The little girl Joanne has existed thus far and is important, so her body and identity need to be considered and kept in mind. Attempts to eradicate unwanted aspects of the self are universally employed by all humans, but it is not really possible… [p228]
A negative therapeutic reaction can sometimes lead to a disruption or even a premature end of the therapy. However, accounts from detransitioners sometimes evidence that it can be that in these dramatic episodes “a seed is sown” and this allows an ongoing positive therapeutic effect… [p229]
John Steiner, in a paper entitled “Time and the Garden of Eden Illusion” (2018), describes a phantasy of the individual returning to an illusory ideal relationship with the mother. This is often connected with an ideal time, place or relationship in the patient’s life before things went wrong. [p230]
You can do surgery on the body but it is mistaken to try to surgically remove a part of the personality. Psychological maturity and mental health are based on an ability to tolerate different aspects of the personality and intolerance does not help psychic integration. As part of the assessment consultation, it is helpful to try to understand what problems the patient had with their given name and what aspects of their personality they were wanting to try to get rid of by transitioning and what ideas they have of whom they are going to become. [p230]
April 21, 2023
I'm a therapist. There seems to be a transphobic opinion on each page so I'm dropping this, discouraging anyone I can from reading it, and moving on.
July 25, 2023
The currently dominant gender affirming care model in the U.S. involves immediately and unquestioningly affirming a child's stated gender identity. This book suggests an alternative approach with more robust mental health counseling for adolescents. The authors worked at the Tavistock gender clinic in the U.K., and their book is made up of case studies to illustrate how the approach would work. There's odd Freudian stuff in here, but overall really interesting.
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June 24, 2024This is a very helpful book.
Displaying 1 - 4 of 4 reviews