Editorial

At the heart of this special issue is a complex and impassioned debate about what gender means both for the individual and for society. Although we rarely receive correspondence at the JCP, a ‘call for papers’ on this topic generated daily emails from members, several of these instructing us on what must be included in this editorial! I encouraged all to write up their experience and concerns into a piece we could publish, and yet only one felt able to do so.

In order to try to describe our difficulty, we need to re-examine what we understand by real: Twenty years ago, child therapists working with fostered or adopted children might routinely refer to the child’s biological parents as the real parents. Bodily facts of life were taken to be a ‘reality’ which should not, could not, be avoided. Since then, our understanding of the primacy of meaningful attachments in the psychological development of the child has been transformed. We understand that attuned nurturing alters the brain, and can promote recovery from complex developmental trauma, and so many of us actively use dyadic therapy or parent-infant psychotherapy as a part of our approach. So nowadays, when children manage to attach to new adults, we often refer to these foster carers or adoptive parents as the real parents and the biological players become something else – possibly even ‘ex-parents’ (Lanyado, 2016, 2017). Though they did not conceive or carry or labour to give the child’s body life, these attached, attuned carers are psychologically the real parents because this is what they are to the child, they are the ones who have done the parenting – vital to psychological conception, holding and development. This does not involve a denial of the biological reality but it does involve a privileging of the relational reality as the most significant in terms of psychological wellbeing. From this perspective, it is not such a big step to agree that gender too is a matter of subjective reality: if I identify as female, I am really a female regardless of how I started out.

However as psychoanalytic therapists, embracing subjectivity wholesale is contrary to some fundamentals of our theory. From a psychoanalytic perspective, the capacities and limits of the human body and how these prompt, design and influence our mental development have a central role. The primacy of an internal bodily blueprint and its psychological corollary, which together create an innate preconception ready to meet with a sensory realisation in order to create thinking (Bion, 1962/1967), is at the heart of this. Over a quarter of a century ago, I brought an observation of three year olds at an inner city nursery to a work discussion group: despite a diverse range of free play opportunities on offer, the boys consistently spent almost the entire time running about with rolled up newspapers pointing them at each other and yelling some equivalent of ‘Fire!’ or ‘Pow!’. These explosive pointy objects might be imaginary guns, light sabres, arrows, rockets, but the group’s interpretation was unanimous – the boys were aware of their possession of a penis and its powerful function even at this early age. Since the penis is so external, this is credible even without a necessary inference of unconscious knowledge. However, more illuminating still was our facilitator’s interpretation of the observation of three year old girls, who spent equivalent time and preoccupation at the ‘making’ table diligently wrapping up boxes as gifts which they would present to their mothers at the end of the afternoon. This senior child psychotherapist, who had published widely on child development, understood the girls’ repeated creative activity as an expression of their unconscious awareness of their capacity to produce a baby, that they had a ‘surprise inside’ which was unconsciously prefigured in the wrapped packages they offered up. At the time there was immediate and easy agreement with this idea from the group – the inherent imperatives of the gendered body were ‘evident’.

The language of ‘drives’, ‘instincts’, of oral or anal phases, of a ‘good breast and bad breast’ are all predicated on the intrinsic consequences of our bodies’ mutual association of actual physical form with function and relationship. The early psychoanalysts leaned heavily on Darwinian theory and, from an evolutionary perspective, it is all about survival and reproduction: nature selects psychology on the basis of staying alive and successfully producing viable copies of one’s genes. In the jungle nothing else matters. Of course there are other ways of thinking about those nursery observations: were the children already unhelpfully gendered by cultural expectation, and would we really see the same behaviour or something less gender restricted if we went back today? However the question remains: how should we, psychoanalytic therapists, think with children and young people who, despite distress and prejudice, declare the primacy of an internal sense of gender and are increasingly prepared to contemplate a lengthy physical transformation to achieve a bodily ‘match’?

Another dilemma about which many of you wrote to us was the difficulty you experienced working in services in which you find yourselves charged with being both therapist and ‘gatekeeper’. The freedom of the analytic space becomes overshadowed by the young person’s preoccupation with being ‘trans enough’ to merit the green light for physical interventions. Perhaps the closest some of us may come to understanding what such a dilemma might feel like for a therapist and a patient can be drawn from our personal training analyses. Many of my own training cohort voiced a similar important dilemma: How could we truly ‘free associate’ on the couch when certain revelations might surely count against the tally of whether we were ready for an intensive patient of our own, or sufficiently self-aware to qualify? How could our analysts truly ‘eschew memory and desire’ (Bion, 1967) if they were to give a thoughtful judgement on the same?

And so to the papers: We set the scene with a commissioned piece from Domenico Di Ceglie who co-founded the Gender Identity Development Service at the Tavistock (GIDS) and has been one of the leading clinician-theorists over the last thirty years. Domenico takes us through a series of metaphors that have helped him navigate previously unchartered territory alongside offering some very helpful practical direction by delineating the goals of psychotherapy with trans or gender dysphoric children, and by outlining the potential benefits and cautions of offering puberty blockers as an intervention. He briefly draws our attention to early results of his research work with Baron-Cohen which investigates the capacities to empathise and systematise within the cohort of young people who are gender dysphoric, and prefigures further research in relation to the high prevalence of autistic spectrum conditions within this same group.

‘Gender/ed Identities’ by Eva Crasnow and Marina Bonfetto stays with this focus on work at the GIDS and gives a fulsome account of their approach which we hope will unlock some of the ‘mystery’ that members working in community clinics have expressed. This is primarily a clinical paper that illustrates the variety and complexity of the life stories of those who are referred, illuminated by their accounts of work with three transgender children and their families. It is particularly striking that the children themselves may present as relatively ‘distress-free’, and it is rather the parents who may be full of anxiety and desperate for help.

For our second commissioned piece we are grateful to Jay Stewart (founder and CEO of Gendered Intelligence, an organisation which aims to help others understand gender in creative ways) for agreeing to work with the JCP by answering some of the ‘frequently asked questions’ that emerged from the concerned correspondence we received from the readership. Jay’s clear and well argued answers cut to the heart of the struggle of the trans community to have their experienced reality regarding gender respected, accepted and supported rather than marginalised as delusional or ‘abnormal’. In particular he points out the difficulty of offering therapy from a position in which a ‘normative’ outcome is preferred by the therapist, even where this is not expressed explicitly. Nevertheless there is more consensus than one might anticipate here: whilst Domenico finishes with the exhortation that we should ‘respond … empathically and flexibly to the particular experiences and story of each individual’ (Di Ceglie, this issue), Jay writes that in terms of what is needed: ‘It will be different from person to person … practitioners need to work with their clients to explore options and decide on what is right for them’ (Stewart, this issue).

From this point we move on to further clinical papers, and these speak for themselves: Hilary Wright’s piece is drawn from doctoral research which charted the movement made by a young person in her weekly psychotherapy towards a capacity to symbolise rather than somatise her internal conflicts. Hilary’s study evidences how their work together helped move this young person on from physical ‘solutions’ to her internal troubles – restricted eating, surgery – and towards a more complex and flexible appreciation of her place in the world that improved her mood, diminished her felt distress, and allowed her to get on with her life. There is more rich clinical narrative in the two papers which follow, both versions of written assignments completed during training. Denise Ray’s likeable 12-year-old intensive patient struggles with embracing his pubertal male body against a back drop of domestic violence and an enmeshed relationship with his mother; his creation of an animated monster ‘Frank’ brings associations with Mary Shelley’s Frankenstein’s monster for Denise, and these lend her compassionate proximity with his attempts to construct a fragile identity for himself. Konstantina Tsoukala’s paper gives a vivid and honest account of her misgivings and insecurities in how to be most helpful to a troubled trans young man, and I hope others will find themselves encouraged, as I did, to follow her finding that some of our most fundamental skills as child psychotherapists – observing, reflecting on, abiding with uncertainty – can be sufficient to offer a meaningful therapeutic space for trans or gender dysphoric young people. We finish the peer-reviewed papers with Mary Brady’s courageous piece about dealing with erotic transference when sexual attraction emerges in the consulting room. Mary alerts us to how quick we are to avoid or deny these feelings, and the positive working through and healthy development that may become possible for our adolescent patients if only we are brave enough to address rather than ignore them.

We round off with our regular features, all on our theme of working with gender identity: child psychotherapists Amanda Keenan and Margaret Rustin, together with Jungian psychoanalyst Robert Withers each offer thoughts about a psychotherapy session with ‘Alex’, a transgender young man at an all-girls school with a history of diverse mental health difficulties. Whilst Keenan points out Alex’s internal conflicts in relation to his own agency and aggression, his parents as a couple and his own sexually maturing body, Rustin also draws our attention to the ‘gang identity’ Alex appears to have discovered in coming out as trans. Withers adds a meta perspective, asking us to consider whether internalised homophobia (in our patients and ourselves) might lead us to avoid challenging trans-identification, but leave us instead practising something perilously close to ‘gay conversion therapy’.

The research digest offers links to a diverse collection of papers on topic, from ethical considerations regarding informed consent to medical interventions, through studies investigating the efficacy of affirmative group therapy, to explorations of the associations of gender dysphoria with eating disorders or attachment style. Finally, in the spirit of promoting open debate, we are pleased to include a book review of a potential controversial new publication ‘Transgender Children and Young People’, by GIDS clinician Melissa Midgen. The book brings together a variety of voices, including social theorists, psychotherapists, persons living as transgender and people who have de-transitioned, who all question, from their diverse perspectives, what they view as a reactionary rather than progressive trend.

So: the issue of who has the right to direct a child’s gender identity remains controversial, and makes its way right into the heart of our consulting rooms. It is hoped that this issue of the JCP will not only illustrate the thoughts and experiences of the young people we meet for psychotherapy, but will also free us as professionals to speak about our own thoughts and experiences with less self-censorship. This remains a tall order when great distress and passionate political positions are involved. We find ourselves in a brave new world where a core and previously binary aspect of identity, assumed to be self-evident and unchanging, is now understood to be complex and fluid or even, quite possibly, socially constructed and redundant. We have much still to learn.

Jo Russell
[email protected]