I welcome the chance to comment on this case, which raises a number of difficult, interlinking clinical and ethical issues. It would be impossible to discuss a case like this without being acutely aware of the fraught political climate currently surrounding gender dysphoria. On the one hand clinical protocols designed to protect trans-people from the danger of ‘conversion therapy’ and ensure access to medical treatment have recently been established (MoU, 2017MoU. (2017). Memorandum of understanding. Retrieved from https://www.psychotherapy.org.uk/wp-content/uploads/2017/10/UKCP-Memorandum-of-Understanding-on-Conversion-Therapy-in-the-UK.pdf). On the other hand there is a danger that effective psychoanalytic work with gender dysphoric individuals could be closed down for fear of falling foul of such protocols and/or being accused of transphobia (Withers, 2018Withers, R. (2018). The view from the consulting room. In H.Brunskell-Evans & M. Moore(Eds.), Transgender children and young people: Born in your own body (pp. 181–200). Newcastle Upon Tyne: Cambridge Scholars Publishing.). The therapist working with Alex faces the difficult task of attempting to sensitively navigate a path between these dangers.
Alex tells his therapist that he hates conflict and ‘very often ends up crying’ when someone such as his father or a teacher shouts at him. This makes him unable to stay composed or argue back as he would like. He becomes affect dysregulated. He seems to cope with this by ‘identifying with the aggressor’. “My inner thoughts” he says, “take the side of whoever attacks me”. He then thinks of himself as an ‘idiot’. This turning of his anger back against himself results in a dissociation from the sadness and vulnerability which he then experiences as ‘not really himself’. By contrast he was so happy when identifying as male on the internet that ‘he decided he wanted to do it for the rest of his life and came out’. Does challenging the obvious defensive aspect of this male identification open Alex’s therapist up to accusations of attempting to practice trans-conversion therapy? How is a clinical supervisor to approach this risk?
Alex is clearly very aware of the power his trans-identification gives him and talks about how he can use it to ‘shut people down’. At one point in the session under consideration the therapist talks of ‘Alex creating himself as Alex’ in order to avoid feelings of pain and vulnerability. Alex counters that it is more like ‘becoming my real self’. A therapeutic impasse appears to have been reached.
Attempts to return Alex to difficult feelings are repeatedly met with resistance. That resistance is reinforced, not only by Alex’s internal trans-identification, but also by the social support he receives for being trans. When you come out as trans, he reports ‘ … there are lots of people behind you’, apparently referring to trans-activists. The therapist chooses to ignore this comment, returning instead to the ‘inner-world’ problems of hurt and vulnerability. Alex dismisses the idea that his trans-identification is a defence against such feelings ‘with a laugh’.
I found myself wondering how the therapist responded internally to this dismissal. What feelings did it evoke? In my own experience, working with people who use the trans-narrative to distance themselves from feelings of vulnerability in this way can evoke hard to reach feelings of hatred in the countertransference (Winnicott, 1949Winnicott, D. W. (1949). Hate in the counter-transference. International Journal of Psycho-Analysis, 30, 69–74.; Withers, 2015Withers, R. (2015). The seventh penis: Towards effective psychoanalytic work with pre-surgical transsexuals. Journal of Analytical Psychology, 60(3), 390–412.10.1111/1468-5922.12157).Is it possible that something similar was happening here? If so, could this constitute a co-creation in the consulting room of a problematic dynamic between Alex and his father? Could such a co-creation be used therapeutically to help Alex regulate his difficult feelings around conflict? I would attempt to sensitively explore the therapist’s awareness of the countertransference at this point with that in mind, while accepting that internalised fears of appearing trans-phobic could render such feelings unconscious. It is worth noting that psychoanalysis has been aware of gender fluidity for a long time. Alex’s therapist could be identifying in the countertransference with Alex’s father whatever his or her biological sex.
I also found myself wondering what would have happened if the therapist had addressed the ‘outer-world’ issue Alex raised. Who are ‘the people behind you’ when you come out? What kind of support is offered by them? To what extent does it depend on continued trans-identification? What might be involved in giving it up? And so on. Of course all this might have led to a similar impasse, but in my opinion, to stay away from a consideration of the outer world because our business as therapists ought to be with the inner world, is to risk missing an important dimension to the trans-narrative. The social acceptance afforded by it can be crucial; especially to people such as Alex who struggle to effectively articulate their feelings in less affirmative, more challenging social settings.
Some psychosomatic issues
Alex clearly finds therapy helpful despite his difficulty regulating affects associated with conflict. But perhaps there is another way of addressing his emotional issues without directly challenging his trans-narrative and the support associated with it. Alex, we learn, is suffering from chronic fatigue, insomnia, stomach pains due to ‘lactose intolerance’, irritable bowel syndrome, and an unspecified eating disorder. He also self-harms. All of these symptoms could be considered ‘psycho-somatic’ in the sense that they simultaneously involve body and mind. From a Winnicott (1966Winnicott, D. W. (1966). Psycho-somatic illness in its positive and negative aspects. International Journal of Psycho-Analysis, 47(4), 510–516.) perspective, such psychosomatic symptoms can both express a desire for the return of the disembodied psyche to a state of ‘psycho–somatic’ integrity and the fear that such a return will entail facing unbearable feelings (unregulated affect).
Near the start of his session Alex relates an incident that happened on holiday, in his usual half amused, half self-righteous tone. His father had ‘lost it’ because Alex had asked him to meet him on the beach with an umbrella, half way towards the group of friends with whom he wanted to sit. Alex does not seem to show any curiosity or interest in his father’s feelings at this point, simply describing them as ‘random’. He is particularly shocked and outraged by what he regards as his father’s insensitive behaviour, because he (Alex) was having a ‘real bad day physically’.
We can see here that Alex uses his physical condition to justify his hurt and angry feelings, much as his therapist suggests he uses his trans-identification. Perhaps his therapist could use this incident to encourage Alex to make sense of his father’s anger. His father has just struggled, without being asked, with two umbrellas from the hotel to the remote beach on which they are sitting. Now Alex wants to sit apart from the rest of the family with his friends and is annoyed that his father does not seem to want to facilitate this. Is his father angry because he feels unappreciated or rejected? And/or does he experience Alex’s fatigue as a passive aggressive attack? At some point it might prove possible to link all this to the dynamics of the transference/countertransference in a way that helped Alex consciously experience, and hence begin to metabolise, feelings associated with his fear of conflict.
If Alex was not ready, or the therapeutic relationship not yet secure enough to do this, it might still prove possible to explore some of the antecedents to Alex’s fatigue. Perhaps un-metabolised emotions from a previous incident or incidents had somehow expressed themselves through the fatigue? It might be possible to help Alex engage with those emotions without raising the resistance associated with a direct challenge to his trans-narrative. This of course would depend upon Alex’s degree of curiosity about himself and his therapist’s ability to enlist that curiosity therapeutically. But at least it would not risk accusations of attempting to practice conversion therapy!
In the final part of the session Alex’s therapist finds a way to help him return to his feelings of vulnerability, but this time in what appears to be a more connected way. Alex is talking about how ‘weird’ he felt before he came out as trans; everyone thought he was “gay, really butch”, he says. His therapist tells us:
Now, I noted, perhaps Alex had got rid of that feeling of ‘weirdness’ and he has gained some sense of legitimacy as he is now known as trans. Alex nodded in agreement but he also looked unexpectedly tired and deflated.
For the first time in the session Alex has dropped some of his defences. But the session is ending and his therapist takes the opportunity to gently remind Alex that despite the trans-identification some of these feelings of weirdness (including his impulse to self-harm and his ‘late night worries’) remain. Perhaps they could be re-visited on another occasion.Absolutely; but if I was supervising this therapist, I would also encourage him/her to explore exactly what this feeling of ‘weirdness’ meant. Self-harm, ‘late night worries’ and by implication feelings of vulnerability, have been mentioned. But Alex himself has explicitly stated that being thought of as butch and gay is an important part of what made him feel weird. So Alex appears to have identified as trans, at least in part, to escape the stigma attached to being thought of as a butch lesbian. The worrying thought arises that a similar difficulty standing up for one’s own nascent, potentially gay, identity in the face of homophobic stigmatisation may have contributed significantly to the current epidemic of young people identifying as trans.
If his therapist affirms Alex’s trans-identity, without adequately challenging this internal and external (partly unconscious) homophobia, could s/he be accused of practicing gay conversion therapy? (See Patterson, 2017Patterson, T. (2017). Unconscious homophobia and the rise of the transgender movement. Psychodynamic Practice, 1–4. doi:10.1080/14753634.2017.1400740 for a fuller discussion of the relationship between unconscious homophobia and the transgender movement.) How is a clinical supervisor to approach this risk?
I mentioned in my introduction that there are a number of difficult clinical and ethical issues associated with this case. My central concern in terms of the remit of this commentary is bound to be with the clinical issues. But the issue just raised is an ethical one. If a therapist addresses the resistance associated with an exploration of the unregulated affect that a trans-identification such as this defends against, could they be accused of attempting to practice trans-conversion therapy under the terms of the MoU? If they fail to do so, on the other hand, are they colluding with the stigmatisation of butch lesbians and hence effectively practicing gay-conversion therapy? This would be against the protocol of the same memorandum. As a supervisor I would hope that it would at least prove possible to have a robust yet sensitive conversation with Alex’s therapist about this issue, even if it could not be definitively resolved.
Clinically this case, as presented, seems to hinge around a difficulty that Alex has metabolising affects associated with conflict. His therapist repeatedly addresses this issue and is not afraid to suggest that Alex’s trans-identification could be a way of attempting to avoid such affects. Alex partially acknowledges this but simultaneously dismisses it with an appeal to the very same identification.
I have suggested three possible ways of tackling this impasse. One is to address the issues associated with conflict avoidance in an arena such as Alex’s psychosomatic symptoms, where an appeal to trans-identification is impossible. The difficulty with this approach is that Alex could make a similar appeal to ‘physical factors’ outside his control, such as physical fatigue or lactose intolerance.
The second, more radical approach would be to address the un-metabolised affects evoked within the therapeutic relationship. To do this it would help if the therapist could become consciously aware of their own countertransference affects; especially the negative ones constellated around episodes of conflict avoidance in the therapeutic relationship. Anxiety about being or appearing transphobic could impede this task. Alex would also need to feel secure enough within the therapeutic relationship to be able to risk experiencing potentially dysregulating affects.
Finally, I have suggested that it is important not to avoid social issues around trans-identification. Identifying as a ‘butch lesbian’ is not currently celebrated or socially affirmed. Hopefully, through therapy, Alex will eventually become better able to withstand some of the social and emotional pressures associated with this. Who knows whether that would result in him dropping his male identification? My sense from the session described is that, whatever happens, he is in good hands.
Notes on contributor
Robert Withers is a Jungian analyst, psychotherapist and clinical supervisor in private practice at The Rock Clinic in Brighton, which he co-founded. He is senior lecturer in mind body medicine (formerly with the University of Westminster, currently visiting the Inter-university College Graz). He has taught and lectured widely on a variety of psychoanalytic topics and trainings. His paper The Seventh Penis; towards effective psychoanalytic work with pre–surgical transsexuals jointly won the Michael Fordham prize for 2015. He is also a contributor to the 2018 book Transgender children and young people; born in your own body (Cambridge Scholars Publishing).
- MoU. (2017). Memorandum of understanding. Retrieved from https://www.psychotherapy.org.uk/wp-content/uploads/2017/10/UKCP-Memorandum-of-Understanding-on-Conversion-Therapy-in-the-UK.pdf
- Patterson, T. (2017). Unconscious homophobia and the rise of the transgender movement. Psychodynamic Practice, 1–4. doi:10.1080/14753634.2017.1400740
- Winnicott, D. W. (1949). Hate in the counter-transference. International Journal of Psycho-Analysis, 30, 69–74.
- Winnicott, D. W. (1966). Psycho-somatic illness in its positive and negative aspects. International Journal of Psycho-Analysis, 47(4), 510–516.
- Withers, R. (2015). The seventh penis: Towards effective psychoanalytic work with pre-surgical transsexuals. Journal of Analytical Psychology, 60(3), 390–412.10.1111/1468-5922.12157
- Withers, R. (2018). The view from the consulting room. In H. Brunskell-Evans & M.Moore (Eds.), Transgender children and young people: Born in your own body (pp. 181–200). Newcastle Upon Tyne: Cambridge Scholars Publishing.