Assessment and treatment of a gender-dysphoric person with a traumatic history

ABSTRACT

This paper presents a composite case based on a group of female-to-male transitioners with a history of trauma due to early separation or family illness. These early traumas may interfere with the process of integrating the mind and body. Symptoms of gender dysphoria often arise from, or increase in response to, subsequent separations later in life, as individuals transition from childhood to adulthood. Increased referrals to gender clinics are noted at puberty or the point of separation from the family, as individuals face the prospect of leaving home to go to university. Affected by anxieties associated with the onset of puberty or separation anxieties, these individuals sometimes seek a medical transition to gain control over their bodies. Exploring underlying psychoanalytic issues can help clinicians assess various conscious and unconscious influences, and help patients make more informed decisions on whether to pursue a medical transition. A focus on defence mechanisms and forms of thinking can help clinicians find ways of working with individuals who may be highly defensive and concrete in their thinking and feel threatened by the functioning of their minds.

KEYWORDS:

• Sexuality
• gender dysphoria
• identity
• adolescence
• trans identity
• psychic retreat
• trauma

Acknowledgments

I would like to thank Susan Evans, John Cohn, Dr Dave Somekh, Dr Roberto D’Angelo, Ian Williamson, Heinz Weiss, Shlomit Gorin, Ema Zane and Bob Hinshelwood for their help in writing this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. This is very common in this clinical area, as a hatred of biological limitations and realities is externalised and dramatised. This often leads to a conflict between the individual that wants to transition and the figures of authority (often parental figures) that question and see it as an act of self-harm that will lead to damage and disappointment. In my view the conflict between Sam and Jane was an externalisation of an internal conflict between Sam’s omnipotent wish to be able to change sex in fantasy as she moved towards her own ideal self-image and the fact of her biological birth, which could not be changed. Sam put pressure on Jane to fall in with her view that transition was possible, achievable and desirable if only Jane would support it. Jane's doubts about the helpfulness of transition were treated as if they were coming from an authoritarian figure rather than a concerned parental figure. Thus, unchangeable facts about the external world are treated like matters of opinion as if winning the argument on opinions makes a difference to the biological body.

Additional information

Notes on contributors

Marcus Evans

Marcus Evans is a psychoanalyst, has previously worked as a consultant psychotherapist and mental health nurse, and has 40 years of experience in mental health. He was head of the nursing discipline at the Tavistock & Portman NHS Trust, a post he occupied between 1998-2018. He was also one of the founding members of the Fitzjohn’s Service to treat patients with severe and enduring mental health conditions and/or personality disorders. He has written and taught extensively and is the author of three books. The first-‘Making room for madness in mental health: the psychoanalytic understanding of psychotic communications’ was published by Karnac in 2016. His second ‘Psychoanalytic thinking in “mental” health settings’ introduces front line mental health professionals to psychoanalytic thinking and was published by Routledge in 2020. His third book was written with his wife Susan Evans – ‘Gender dysphoria: A therapeutic model for working with children, adolescents and young adults’ and was published by Phoenix in 2021.