By Robert Withers, MPhil, Bac, RS
Robert Withers is a Jungian analyst, psychotherapist and supervisor at the Rock Clinic in Brighton England; which he co-founded. He is also senior lecturer in mind-body medicine at the inter-university college Graz. He has worked with a number of trans identifying people in various stages of transition and de-transition. He has a special interest in the psychology of gender dysphoria and has published several articles and lectured widely on the subject. His 2015 article “The Seventh Penis; Towards Effective Psychoanalytic Work with Pre-surgical Transsexuals” in the Journal of Analytical Psychology jointly won the Michael Fordham prize. Other publications on the subject to date include “The View from the Consulting Room” in the book Transgender Children and Young People: Born in Your Own Body and a “Clinical Commentary by Robert Withers” in the Journal of Child Psychotherapy January 2018.
Find him at Twitter @BobWithers42
This conference was funded by Pfizer pharmaceuticals, though apparently the Tavistock Gender Identity Service was given total freedom regarding the subject matter of the symposium.
Professor Gary Butler of UCLH and the Tavistock GIDS introduced proceedings. He remarked that no chromosomal, hormonal, or other physical anomalies had been detected in the clinical population using the GIDS, despite initially screening for these.
Dr Polly Carmichael, head of the GIDS and a clinical psychologist, went on to give the first talk. It concerned the differences and similarities between gender dysphoria and sex development disorders. Surprisingly, given her profession and the stated purpose of the conference, Polly did not mention psychological factors influencing gender development. Instead she emphasised genetic, biological and social elements. When questioned about this omission she described it as a ‘Freudian slip’. The omission is surprising given the Tavistock’s position as a leading psychoanalytic clinic and the preoccupation with identity development in psychoanalysis. Freud’s (1917) Mourning and melancholia, Winnicott’s (1967) ‘mirroring’ and the Boston Change Process Study Group’s recent (2010) work on the role of implicit relational knowing in the construction of the inner world are all deeply concerned with the development of identity.
Unfortunately, this reluctance to address psychological factors proved to be a feature of the conference. There was not a single talk on the role of psychological factors in the aetiology of gender dysphoria or gender identity. But Professor Riittakerttu Kaltiala-Heino, an adolescent psychiatrist from Tampere Finland, did acknowledged the importance of a psychodynamic perspective. She spoke about her clinical experiences- including her work with ‘adolescent onset gender dysphoria’, sometimes known as ‘Rapid Onset Gender Dysphoria (ROGD)’. She made several important points, observing for instance that in Finland, as elsewhere, psychological co-morbidities remain largely untreated because psychotherapists wrongly believe that only gender identity specialists should treat GD patients. In her experience, such co-morbidities are likely to persist if they are not addressed psychologically before medical treatment. Interestingly she also mentioned that several of her patients seemed to share an identity. Many of the young FtMs in her care claimed to have spent large parts of their childhood alone in the woods fantasising about being a male wolf for instance. She acknowledged privately that this was probably due to social contagion via the internet as people were encouraged to provide the sort of history that would facilitate their medical transition.
In contrast Professor Sarah-Jayne Blakemore of UCL spoke about the science of brain development in adolescence. She outlined the move through adolescence from puberty to the establishment (if all goes well) of an independent role in society by about the age of 26. Over this period a kind of pruning happens in the social brain network. Grey matter shrinks, and white matter increases in areas of the brain associated with social interaction as connections between and within these areas become myelinated. This process is mediated by the sex hormones of puberty and a cascade of effects occurs down a specific time line. Puberty blockers are likely to interfere with this, but exactly how is currently unknown.
We do know something of the effect of puberty blockers on the brain development of adolescent sheep however. Professor Neil Evans of the Institute of biodiversity in Glasgow reported impairments to several functions- including a sheep’s capacity to find its way through a maze- which persist after stopping puberty blockers. This raises questions about the possible neurological effects of puberty blockers on children’s psychological, social, sexual and cognitive development. Some of Professor Evans’s references are listed below (Robinson et al 2014, Hough et al 2017 a & b).
Puberty blockers have been approved for precocious puberty in humans, but their use in gender dysphoria remains off label. My understanding is that this means that individual doctors (in the USA) and NHS trusts and their doctors (in England) not the drug companies will be liable for any eventual compensation claims. Carmen Mironovici (a paediatric endocrinologist) estimated that the cost of such treatment (in the USA) is currently $15,000 per year.
A couple with a gender dysphoric child and a natal female who had started testosterone treatment and then stopped it after embarking on psychotherapy, kindly shared their experiences with the audience. It became clear that the current set up at the GIDS typically only offers six psychological assessment sessions and a similar number of family therapy sessions with little or no meaningful ongoing individual psychotherapy. This is inadequate for a client trying to deal with serious comorbidities such as childhood sexual abuse, autism, attachment issues, body hatred and/or struggles with their sexuality- including internalised homophobia. And it seems likely that in at least some cases such psychological issues play a significant role in the aetiology of trans identification.
On the first evening, a series of clinical case scenarios and the ethical issues raised by them were discussed in small groups and précised for a plenary session. One case was that of a young person who had been diagnosed gender dysphoric and prescribed puberty blockers by the GIDS. They had been fortunate enough to receive meaningful psychotherapy and as a result came to realise that their trans identification had been a reaction to psychological trauma. Some of the ethical issues raised were these. How often are trans identification and puberty blockers currently being used by clinicians, clients and their families to evade the investigation of painful psychological issues? How ethical is the use of puberty blockers given our ignorance of their long-term effects? Do they buy time for a GD young person to explore their options before deciding whether to embark on full physical transition, or do they increase the probability of medical transition? Another question that could have been raised is whether the lack of effective psychotherapy at the GIDS is really justified, given the high cost and potential side effects of puberty blockers.
There is not enough space in this review to outline all the talks, let alone critique them all effectively. Dr Vibe Frokjaer of Denmark spoke informatively on the role of hormones in the aetiology of mental health problems, including depression, in women. Dr Annelou de Vries quoted a 2011 Dutch study by Steensma et al which indicated that childhood gender dysphoria only persists past puberty in 15% of cases, while 75% persist if still dysphoric after the onset of puberty. Some talks dealt with the genetics of gender (or more properly sex) development (Skordis). Some (Fisher, Seal) summarised the research on the effects of medical intervention on bone, cardio vascular and cancer morbidity. Effects were complex and varied depending on the length of time of the study, the precise nature of the treatment and the gender of the patient. Trans men’s health generally fared better than trans women’s. A long-term study by Asscherman et al (2011) showed a 51% increase in mortality among medically treated trans women. This was mainly due to suicide and HIV/AIDS.
Dr Leighton Seal of the Charing Cross (adult) Gender Dysphoria Clinic reported an 80% reduction in psychological symptoms 78% improvement in well-being and 72% improvement in sexual function among his subjects post medical transition. It is unclear how this squares with the long term increased suicide risk however. Dr Seal also claimed that a (Zhou et al 1995) post mortem study of seven trans women all of whom had received female sex hormones, six with full orchiectomies, provided good evidence that gender dysphoria was caused by abnormalities in foetal brain development. It is hard to understand how he reached such a conclusion.
For me this symposium failed in its central aim of helping distinguish the respective roles of nature and nurture in gender development and gender dysphoria; largely because it failed to give due weight to psychological factors. Perhaps this is to be expected from a conference sponsored by a large multi-national pharmaceutical company. Nevertheless, it was a very welcome conference, which facilitated informative, at times robust, but generally mutually respectful discussion among a group of professionals from all over the world. I look forward to a similar but more truly interdisciplinary conference in the not too distant future.
Bob Withers 23.10.18 email@example.com
Asscheman et al 2011 A long term follow-up study of mortality in transsexuals receiving treatment with cross sex hormones. European Journal of Endocrinology (2011) 164 636-642
Boston Change Process Study Group 2010 Change in Psychotherapy a unifying paradigm New York: Norton
Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 237-258
Hough D et al., 2017a Spatial memory is impaired by peripubertal GnRH agonist treatment and testosterone replacement in sheep. Psychoneuroendocrinology. 75:173-182.
Hough D et al., 2017b A reduction in long-term spatial memory persists after discontinuation of peripubertal GnRH agonist treatment in sheep. Psychoneuroendocrinology 77:1–8
Robinson JE et al. 2014 Effects of inhibition of gonadotropin releasing hormone secretion on the response to novel objects in young male and female sheep. Psychoneuroendocrinology 40:130-139
Steensma et al (2011) Desisting and persisting gender dysphoria after childhood; a qualitative follow-up study Clin Child Psychol Psychiatry 2011
Winnicott 1967 Mirror-Role of the Mother and Family in Child Development in Playing and Reality 1971 Tavistock Publications
Zhou, J-N., Swaab, D.F., Gooren, L.J. & Hofman, M.A. (1995). ‘Sex difference in the human brain and its relation to transsexuality’. Nature