Trans-itory identities: some psychoanalytic reflections on transgender identities

ABSTRACT

The capacity of transgender to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality “trans” has become a central cultural site. In this paper, I will argue that this identity label encompasses a complex range of internal psychic positions in relation to consciously stated sexual preferences and gender identifications. My aim is to explore what can appear to be in some cases a premature embracement of the empowering potential of the transgender identification through my work with under 18-year-olds who are seeking medical intervention for gender dysphoria. This can undermine the painful psychic work required to establish what transgender means for any given young person. In an external culture where to ask “why transgender” (as opposed to “how transgender”) is felt to be pathologising, working with these young people can prove difficult for the analyst. The challenge is to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function that is core to an analytic approach, and a posture of implicit skepticism.

La capacité des transgenres à incorporer toutes les différences de genre et orientations sexuelles est devenu un outil de militantisme et d'identification personnelle. Plutôt que de constituer un indicateur de marginalité, le phénomène « trans » est devenu un espace culturel central. L'auteure de cet article soutient que ce marqueur d'identité englobe toute une gamme complexe de positions psychiques internes en relation avec des orientations sexuelles et des identifications de genre consciemment exprimées. Via son travail avec des adolescents âgés de moins de dix-huit ans qui réclament une intervention médicale pour une dysphorie de genre, elle vise à explorer ce qui dans certains cas peut apparaître comme une adhésion prématurée au potentiel valorisant de l'identification transgenre, ce qui peut saper le travail psychique douloureux nécessaire pour définir ce que signifie être transgenre pour un jeune adulte donné. Au sein d'un environnement culturel extérieur, où la question du « pourquoi transgenre » (par opposition à celle du « comment transgenre ») est considérée comme anormale, le travail auprès de ces jeunes peut s'avérer ardu pour l'analyste. Le défi consiste à parvenir à un juste équilibre entre l'instauration d'un dialogue fondé sur une curiosité à égale distance entre la signification et la fonction, ce qui est l'essence même de l'approche analytique, et une attitude de « méfiance éclairée », qui a très peu de chance d'aboutir à un dialogue constructif.

Die Fähigkeit des Transgender, sämtliche Gendervarianten und sexuelle Präferenzen abzudecken, ist zu einem wirkmächtigen Instrument des Aktivismus und der persönlichen Identifizierung geworden. „Trans“ verweist nicht länger auf Marginalität, sondern hat sich zu einem zentralen kulturellen Schauplatz entwickelt. In diesem Beitrag führe ich aus, dass diese Identitätsbezeichnung eine komplexe Bandbreite innerer psychischer Einstellungen gegenüber bewusst erklärten sexuellen Präferenzen und Genderidentifizierungen erfasst. Ich möchte eine in manchen Fällen übereilt wirkende Aneignung des Stärkungspotentials der Transgender-Identifizierung untersuchen, und zwar ausgehend von meiner Arbeit mit Unter-18-Jährigen, die wegen Genderdysphorie um eine medizinische Intervention nachsuchen. Diese kann die schmerzvolle psychische Arbeit untergraben, die notwendig ist, um zu klären, was Transgender für den individuellen jungen Menschen tatsächlich bedeutet. In einer äußeren Kultur, in der die Frage „Warum Transgender?“ (im Gegensatz zu „Wie Transgender?“) als pathologisierend wahrgenommen wird, kann die Arbeit mit diesen jungen Leuten für die Analytikerin extrem schwierig sein. Die Aufgabe besteht darin, sich auf dem schmalen Grat zwischen einem Dialog, der auf der – das analytische Vorgehen auszeichnenden Neugier bezüglich Bedeutung und Funktion beruht, und einer Haltung des „begründeten Misstrauens“, die einem produktiven Dialog schwerlich zuträglich ist, zu bewegen.

La capacità di incorporare l’intero spettro delle variazioni a livello sia di genere sia di preferenze sessuali ha fatto dell’etichetta di ‘transgender’ un potente strumento di attivismo e di identificazione personale. Lungi dal rappresentare un indicatore di marginalità, l’area ‘trans’ ha anzi acquisito un posto centrale nella nostra cultura. Nel presente lavoro mostrerò come in realtà questa etichetta identitaria racchiuda in sé un complesso insieme di posizioni psichiche interne rispetto alle preferenze sessuali e alle identificazioni di genere espresse consciamente. Il mio scopo è di esplorare, traendo spunto dal mio lavoro con giovani di 18 anni che hanno fatto richiesta di interventi medici per la disforia di genere, quella che in alcuni casi potrebbe apparire una prematura rivendicazione del potenziale di empowerment che l’identificazione transgender può offrire. Una situazione di questo tipo può mettere a repentaglio il doloroso lavoro psichico necessario per stabilire che cosa ‘essere transgender’ significa per ciascuno di questi giovani.

Laddove ci si confronta con una cultura esterna per la quale la domanda ‘perché transgender?’ (anziché ‘transgender come?’) è avvertita come patologizzante, lavorare con questo tipo di giovani pazienti può riuscire difficile per l’analista. La sfida, in questi casi, sta nell’usare la massima prudenza nel distinguere tra un dialogo caratterizzato da una curiosità equidistante rispetto al significato e alla funzione – posizione, questa, essenziale per un approccio analitico efficace – e un atteggiamento di ‘sospetto informato’ che viceversa difficilmente aiuta a impostare un dialogo produttivo.

La capacidad del transgénero de incorporar todas las variaciones de género y preferencias sexuales se ha convertido en una poderosa herramienta de activismo e identificación personal. En lugar de ser un índice de marginalidad, “trans” se ha vuelto un espacio cultural central. Aquí, la autora sostiene que este término identitario abarca una gama compleja de posiciones psíquicas internas respecto a preferencias sexuales e identificaciones de género conscientemente declaradas. A través de su trabajo con menores de 18 años que buscan intervención médica para la disforia de género, la autora explora lo que en algunos casos parece ser una adopción prematura del potencial empoderador de la identificación transgénero. Esto puede socavar el doloroso trabajo psíquico de establecer qué significa transgénero para cualquier persona joven. En una cultura externa donde preguntar “por qué transgénero” (en oposición a “de qué manera transgénero”) es sentido como patologizador, trabajar con estas personas jóvenes puede resultar difícil para el analista. El desafío es mantenerse sobre la delgada línea entre el diálogo basado en una curiosidad equidistante acerca del significado y la función que es central para un enfoque analítico, y una postura de “sospecha informada”, que es poco probable que fomente un diálogo productivo.

KEYWORDS:

• gender identity
• transgender
• adolescence

Waiting is directed at nothing: any object that could gratify it would only efface it. Still, it is not confined to one place, it is not a resigned immobility; it has the endurance of a movement that will never end and would never promise itself the reward of rest; it does not wrap itself in interiority; all of it falls irremediably outside.

MICHEL FOUCAULT, “The Thought of the Outside”, Aesthetics, Method, and Epistemology

Identity in modern times

Freud only used the term “identity” once in his writings in a speech delivered to a Jewish society in Vienna:

What bound me to Jewry was, I am ashamed to admit, neither faith nor national pride, for I have always been an unbeliever and was brought up without any religion though not without a respect for what are called the “ethical” standards of human civilization. Whenever I felt an inclination to national enthusiasm I strove to suppress it as harmful and wrong, alarmed by the warning examples of the peoples among whom we Jews live. But plenty of other things remained over to make the attraction of Jewry and Jews irresistible - many obscure emotional forces, which were the more powerful the less they could be expressed in words, as well as a clear consciousness of inner identity, the safe privacy (Heimlichkeit) of a common mental construction. And beyond this there was a perception that it was to my Jewish nature alone that I owed two characteristics that had become indispensable to me in the difficult course of my life. Because I was a Jew I found myself free of many prejudices which restricted others in the use of their intellect; and as a Jew I was prepared to join the Opposition, and to do without agreement with the “compact majority”. (Freud 1926, p. 272)

Three aspects are striking in Freud's first reference to the notion of identity. First, he describes the connection between a personal experience and larger social forces. Second, he notes the pull of the “attraction of Jewry and Jews”. Third, and most importantly, Freud makes an oblique but clear reference to the emotional and unconscious aspects of identity (“many obscure emotional forces”) that often remain ignored in contemporary discussions about identity.

No matter how we define it, identity has emerged as something of a “master signifier” in many of the humanities and social sciences (Alvesson, Ashcraft, and Thomas 2008). The concept itself has not found a place in metapsychology (Birksted-Breen 2016) but how an identity is forged through processes of projection and introjection and the compromises it rests on is of central psychoanalytic interest. Of all the disciplines concerned with defining “selfhood” or “identity” psychoanalysis is the boldest in decentralising and destabilising any such notions by introducing the subversive machinations of the unconscious and the “speciousness” of identity itself (Frosh 1991). Tying down identity primarily to social processes and conscious choice denudes the notion of its essentially conflictual nature and of its intimate connection with desire and unconscious phantasy.

“Choice” has nevertheless come to the forefront of discussions of identity construction in late modernity. Numerous social commentators (Bauman 1988; Sennett 1998) have offered convincing arguments that an unprecedented degree of freedom has opened up for people, at least those living in industrialised countries of the West, along with the shrinking of social institutions. Life has become increasingly atomised as freedom of choice and the right to self-realisation emerge as guiding principles. Indeed it could be argued that nowadays we are expected to present ourselves as biographically flexible and open to change. This freedom of choice finds its epitome in the ability to customise one’s body – a trend modelled on consumer choices under the dominance of the neo-liberal consumerist concept with the attendant risk that identity is based on what I am calling “acquisitive imitations” (Lemma 2015) where imitation trumps identification (see Gaddini 1969).

Through the staggering advances in technology (and I am using the term here in its broadest sense to encompass medical and cybernetic technologies) we can now manipulate our bodies in actuality and virtually and hence our so-called identity. The body is central to the construction and disruption of identity coherence. Nowhere is this more apparent than in the varied experiences of people who describe themselves as transgendered and seek to modify their bodies to make them more congruent with the subjective experience of gender identity.

The sexed body, social gender and sexuality (i.e. desire) – distinctions first elaborated by the early twentieth-century sexologists – are all constitutive of identity. Gender identity is not causally related to sexual desire and both are nowadays conceptualised as independent of sexed bodies. The value of an analytic perspective on gender and sexuality is that it reveals that the relationship between a body part and its sexual function or its gendered significance is at best one of “lightly tethered consonance rather than a rigidly shackled indexical mapping” (Salamon 2010, p. 40). The psychic investments that we have in our bodies are key to understanding the subjective experience of embodiment and hence need to be reflected upon in our theorising about any kind of identity. The body is the primary site of inscription and meaning arising from external forces as well as internal, unconscious ones. Severed from its unconscious psychic investments, the materiality of the body has no meaning. It is only “real” as flesh and bones.

In this paper, I want to build on previous work (Lemma 2013, 2016) and suggest that understanding the breadth of meaning and function that is subsumed under transgender as an identity referent is helped if we think not only in terms of societal “gender” inscriptions but also in terms of the subjective experience of embodiment, of the body’s unconscious identifications and hence the psychic function of the modification of the body.

This paper is focused on work with under 18-year-olds who are seeking medical intervention and for whom “being transgender” becomes an organising identity post-puberty with no consistent prior history of conflict about gender per se. My aim is to explore what can appear to be, in some of the cases where medical intervention is sought,¹ a premature embracement of the empowering potential of the transgender identification. This state of mind can undermine the painful psychic work required to establish what transgender means to the young person – an understanding that is critical to post-operative adaptation if they are intent on body modifications to reduce the felt incongruence within the given body.

The heterogeneity of transgender identities and experience

Referrals of young people to gender identity services have increased exponentially. The Tavistock and Portman NHS Trust that provides the national gender identity service in the UK for under 18’s reports that the number of referrals to the unit has risen approximately 10-fold between 2011 and 2017 (Butler et al. 2018). The increasing prevalence of gender variance in the broader population has led to many changes, for example, in language where the preference nowadays is for non-gender specific pronouns and the 71 gender options on Facebook profiles, and has also led to new legal gender categories in some countries (Stryker 2017). The societal changes with respect to the very notions of gender are significant and require thoughtful reflection across many disciplines and they are more far reaching than just for the transgender community. The Gender Recognition Act (GRA) currently debated in the UK in 2018 is a case in point: proposed changes to GRA would allow, for example, a natal man to self-identify as a woman and vice versa even if they had not undergone any surgery. This is a fundamental change in how we define “woman” and “man” in law thereby subsuming given biology to self-certified identity.

Transgender – a term coined in the early 1990s – is now understood as a collective category of identity that encompasses a very diverse array of male and female bodied gender variant people and sexualities (e.g. transvestites, transsexuals, drag queens, gender queer, intersexuals, fem queens, butch lesbians, female embodied masculine persons) (Bolin 1994; Califia 2003; Valentine 2007). Transgender is thus an umbrella term that describes someone whose gender identity or expression does not match the gender they were “assigned at birth”, a common phrase that is used underscoring how people feel that sex and gender are given at birth, rather than being innate or unchangeable qualities. While some transgender people transition from one side of the gender binary (e.g. man/woman, masculine/feminine) to the other, some prefer to exist in between, or outside the binary altogether.²

The capacity of “transgender identity” to incorporate all gender variance and sexual preferences has become a powerful tool of activism and personal identification. Rather than being an index of marginality “trans” has become a central cultural site (Valentine 2007). It is clear, however, that the term encompasses a range of internal psychic positions in relation to stated external sexual preferences and gender identifications. My experience over 30 years of work with adolescents is that we are now seeing an increasing number of young people who are very confused about their sexual and gender identity, who struggle to sustain relationships with either gender and who are distressed but who appear to manage this by identifying with “transgender”. For some this eventually leads to full transitioning, including sex reassignment surgery (SRS). An increasing number of my referrals over the past five years in particular have been of young people who identify as “trans” but who have no intention to fully transition, but are nevertheless keen to customise the body. For example, they may want to pursue some medical interventions such as hormone therapy or, if they are natal girls, they may have “top surgery” but not proceed to phalloplasty or take testosterone.

The sub-category of transgender young people that I am encountering clinically and focusing on here captures the experience of individuals who appear to be performing “psychic surgery” through more or less enduring modifications of the body, or fantasies about its modification, and then stitching together an identity that is precariously “trans-itory”. I am not suggesting this is the case for all transgendered individuals, but it is important to be able to reflect on the function that the identity “trans” may serve for some people.³

Understanding transgender requires us to formulate at the intersection of socio-cultural processes and individual psychodynamics that implicate the analyst as much as the patient as both need to make a sustained effort to question the signifiers that shape our individual relationship to our bodies. This invites us to reflect on the central role of the body in the development and maintenance of identity both when development is proceeding well as much as when our identifications with an identity label or group become ways of managing disruptions in identity or its fragmentation.

Let me be clear: I can only share formulations based on the young people I have seen who are, admittedly, a highly selected group given that they have chosen to come to therapy or have been sent there by parents. However, they are representative of at least one section of the transgendered population. Indeed the few longitudinal follow-up studies that have been published in the Netherlands have generally shown a high satisfaction outcome, particularly from those who have gone through surgical affirmation of their identified gender (de Vries et al. 2011, 2014).⁴ We do well to keep in mind this type of research finding. However, we also need to attend to the experience of those young people for whom medical intervention may not be the solution to their distress even if they identify as transgender.

In an external culture (including within our own discipline) where to ask “why transgender” (as opposed to “how transgender”)⁵ is felt by some to be pathologising, working with these young people can prove very challenging for the analyst. Setting aside these external pressures, the real challenge is how to tread the fine line between a dialogue based on an equidistant curiosity about meaning and function, which is core to an analytic approach and, I will argue, needs to be preserved in relation to the question of transgender (just as in any exploration of the experience of embodiment and sexuality whatever its orientation), and a posture of “informed suspicion” (Wren 2014, p. 282) that is unlikely to foster a productive dialogue. Questioning motivations, wishes, fantasies and fears from a position of equidistant curiosity is not about coercing someone to follow a pre-determined “healthy” path. It is about helping people find the best possible way to live for them mindful of the emotional (and physical) costs and risks of their decisions.

Some illustrations

Anita is a drag queen. She is on hormones but has not had a sex change or is planning to have one. In this brief interview excerpt taken from an ethnographic study of the term “transgender” (Valentine 2007), Anita (A) claims a number of different identities: drag queen, female, male and gay. I will quote this striking exchange with the interviewer (I) since it is a published study and not my own so that it is entirely independent and provides another perspective on some of the issues under discussion.

I:

Do you know what this term transgender means?

A:

No

I:

You have never heard it before?

A:

No

I:

Do you know what transsexual means?

A:

Transsexual means a sex change right?

I:

Yes. You don’t consider yourself to be a transsexual?

A:

No

I:

Ok. But do you consider yourself to be a woman?

A:

Yes, yes, but I know what I am – I know what I am, but I … I … you know … ., I treat myself like a woman, you know I do everything like a woman. I act like a woman, I move like a woman. I do everything like a woman.

Anita then describes herself as “gay”.

I:

You consider yourself to be gay then?

A:

Yes!

I:

Even though you live as a woman … 

A:

Yes

I:

Right, Ok … 

A:

I know I’m gay and I know I’m a man.

Later in the same interview Anita states that even though she does not consider herself to be a woman or a transsexual, she adds: “But I don’t want to go back to being a man”, implying that even though she knows that she is not a woman, she also does not feel that she is a man.

Anita’s description of her own positioning in relation to her gender and sexuality resonates with my experience with some young transgendered people who are exploring who they are along an ever-shifting spectrum of sexual and gender identifications. The subjective experience of gender and the process of adolescence are both characterised by fluidity and uncertainty (Fausto-Stirling 2012). At times the dialogue one has with young transgendered people can come across as confused and confusing (this could be one of several readings of Anita’s replies); at others one senses a fluidity of identifications that permits a “trying on for size” of different identities until a more integrated sense of self emerges. What is clear with my young patients, however, is that, for example, “being a man/woman” or “wanting to be a man/woman” cannot be reduced to one simple meaning or desire that is constant. Tolerating ambiguity and the undoing and reconstructing of identity narratives is the challenge faced by the young person and the analyst working with them.

Jane had just turned a 17 the day before I first met her. I worked with her over five years once weekly, face-to-face. She came to see me because her parents became concerned after she cut short her previously long hair and told them that she wanted to be a boy. Jane had never said this before, or even consciously thought it, she told me at our first consultation. And yet she was now clear that she was “trans”, that “being born in the wrong body” provided a persuasive account for her longstanding unhappiness and difficulty in establishing a sexual relationship with boys. Around this time a female school friend who had a crush on her declared her attraction to Jane. Even though Jane had not reciprocated she told me that she was keen to explore a homosexual relationship – except that she did not see it as such in her mind now because it was her “really a boy” self that liked the idea of sex with a girl and hence this was not “me being a lesbian”.⁶

My impression on first meeting Jane was that she was somewhat confused about who she was. Now that the idea of being “trans” had taken hold in her mind she frantically searched the Internet for information about transitioning. Uncertainty was replaced by the certainty of an identity that could now be named and recognised by others. This evidently brought her comfort and relief: she felt that she was now able to see a future for herself whereas before she felt lost and alone. She excitedly shared with me the transgender support groups with which she was now linked. It was clear that she experienced herself as more connected to people who helped her to feel that she was visible and intelligible.

In her day-to-day life, Jane wore androgynous clothes and her hair was kept immaculately short. She had thrown away all her make-up, denigrated her previous “girlie” self and spent hours (literally) studying You-tube videos of her favourite male You-tubers to “learn” male mannerisms that she then tried to emulate. She would stand in front of the mirror in her bedroom and practice. Sometimes these “practice” sessions ended in tears as she thought she could not pass convincingly; at other times she relished being mistaken for a boy in the street only to then feel crushed by the sound of her feminine voice that betrayed her assigned sex to the world.

In her online gaming her avatar was now a male one. Jane felt happiest when on-line because there she said she could be the boy she felt herself to be. Her new male persona (Jake) could “breathe” online, as she put it, and hence cyberspace became all consuming, not least because her parents were putting her under considerable pressure to “come to my senses” and focus instead on her pending exams. Being in cyberspace and relating to others through the medium of technology was her safe retreat from the pressures of reality but it was also a space in which Jane was working very hard to find out who she was. She was “playing with reality” to define the contours of her identity through finding an embodied form that could guarantee what she felt she lacked.

Jane was an only child born to a teenage mother who had given her up for adoption at birth. She had been adopted as a baby into an affluent family that was in many respects stable but both parents seemed rather conservative in their outlook on life. Jane’s declaration that she was “trans” came as a shock to them and they did not feel equipped to deal with this. Her adoptive mother was described as “kind but weak”. The adoptive father was described as “conventional and serious” and very successful in his field of work. She told me that her adoptive mother had wanted more children but the father had not agreed because of his work commitments.

The session I will report here was the third consultation.

I asked Jane about her biological parents, as she had made no mention at all about them. She was dismissive in her reply, saying that she had no interest in them and that she did not think that her difficulties were connected to being adopted.

I said that she was making it very clear that she did not want me to write off her feeling that she was a boy with some off-the-shelf interpretation about adoption.

She seemed relieved when I said this adding that she had felt all her life that her problems had been put down to that, but that she was clear that her adoption had nothing to do with anything. She emphasised that she had never been curious about her biological parents. She had been told that her biological mother had “difficulties” and could not look after her. She knew nothing about her biological father except his nationality and that he had not supported the mother when she became pregnant.

After a silence Jane said that her adoptive mother had bought a book I had written – “probably to check you out”, she added pointedly – and that when she had picked it up Jane had noticed that I had made a reference in the acknowledgements to a male name whom she presumed to be my son. She was quite sure I must have a son and in fact she imagined I had more than one son. I was struck by the certainty of her assumption as if there could be no place in my mind, or hers, for a girl.

I replied that perhaps she too was trying to “check me out” and determine if I preferred boys or girls.

“Well do you have a preference?” she then asked provocatively.

I replied that she seemed very preoccupied with what was in my mind about boys and girls and whom I might prefer and what I thought about her decision to become a boy.

“I have not decided to become a boy. I am becoming who I should always have been. That’s quite different”, she added angrily.

I agreed with Jane that there was a difference but that in fact I had put it that way because, rightly or wrongly, that was how I heard her: that she had “decided” a few months ago that she was really a boy even though she had never before been concerned about her gender identity. I could also hear that this made her angry and I said that I hoped she could help me to better understand her position since she seemed to feel I misunderstood her.

Jane said that she had always hated her body and that she lost years going down the wrong track of thinking she was ugly (and that was the reason why boys were not keen on her) instead of realising that she was just in the wrong body. She said that she had never told anyone she hated her body because she did not think she would be taken seriously. She added that online or when playing through her male avatar – Jake – she felt finally at ease in her body.

I said that she was worried I was not taking her seriously.

She said she was seeing me only because her parents would not let her take hormones unless she saw me.⁷ She did not expect me to understand her. But she had to go through the motions.

I said that given she felt she had to see me we could at least make the most of the time we had together to understand what it felt like to be her and help her get through this difficult time in her life. Jane nodded.

I then asked her to describe to me a bit more what she felt like when she was playing online as Jake as I sensed that she had come alive when she recalled her online life.

Jane relaxed visibly and told me that when she was online as Jake she felt free, as if she could now do and say things that in her real life female body she could not. She said that she was like she imagined she should have always been. She placed particular emphasis on how she enjoyed the feeling of Jake running because “his legs are strong and it looks like he can go wherever he likes”. She enjoyed the sensation of strength in her body and whilst on line she sometimes felt “as if my actual body is more substantial”. Sometimes this feeling carried over after she signed off and that made her feel more like going out and being with others.

I observed that her male avatar, Jake, made her feel she was strong and could help her to get away from a place inside her body and mind where she felt very ill at ease and unhappy. I added that feeling “substantial” seemed important to her and that she felt this way when she expressed herself and related to others though Jake.

Jane said she had always felt unhappy but had never understood why she felt so bad. When relating to others through Jake, or when she used her male persona on line, she told me that others had respect for her, took her seriously and related to her as a strong person that “you would not mess around with”.

I said that being a boy seemed to make her feel more attractive and confident, safer from attacks by others … more substantial … 

She said that she could now not even understand how she had managed to be so “girlie” for so long.

I asked her what “girlie” meant.

In her reply Jane gave a very caricatured picture of a “princess” girl: someone into pretty prints, obsessed with make-up and boys, and with “no brain”.

I observed that it sounded like a bit of a cardboard cut out Princess that had no substance.

Jane replied in an animated way: “Exactly! That’s what I was trapped inside. That’s why it’s so liberating to cut my hair, change my clothes and breathe!! Now I feel that I am someone. Well … what I mean is that I’m me … ”

I said she seemed to have felt quite trapped but I wondered whether she had been feeling trapped in the wrong sexed body or in an experience of herself that lacked substance … someone who failed to make an impression on others.

Jane paused for a minute and then said that her father was very stuck in gendered roles and that her mother had been stuck in a “hostess” role much of her life. Her mother was very invested in what other people thought, in the appearance of things, but actually Jane thought that her mother was the kind of person that did not make much of an impression on people: “All those pretty dresses, all the lovely well-plumped-up cushions, but I’m not sure anyone really thinks she has a brain … .But this has nothing to do with what’s happening to me”, she added, “I know I’m trans, a boy, and that’s what I need to follow.”

I commented that no sooner had she allowed us both to take an excursion away from the “I am trans and I need to take hormones” track and to think more generally about what it felt like to be in her girl self and body, she had done a U-turn back into certainty about “really being a boy”.

And so it was for quite some time: alternating between anger towards me for what she perceived to be my attempts to get her to think about something other than her wish to transition and brief moments when some other feelings and thoughts could be aired and explored. I sensed that Jane wanted to meet with me as if or conversations, however uncomfortable and fraught at times, were also a lifeline. An important breakthrough came a year into the therapy when Jane told me that in her biological mother’s culture of origin boys were more highly prized. She had sometimes wondered whether if she had been born a boy her mother might have kept her.

As the therapy progressed Jane spent less time online and related to others online as Jane. Her former male avatar became a tall, strong woman who had breasts and athletic legs. Jane continued to struggle with what she perceived to be her actual small frame. Through her new female avatar’s embodied form she expressed the need for a sturdy frame to give her the strong foundations and stability she felt she needed to be herself in the world. Part of this process eventually involved tracing her biological mother. In the final year of our work, when Jane was by then 21, she started a relationship with a girl but it was clear that she was also drawn to boys. She defined herself as bisexual.

Discussion of clinical material

By the time we stopped working together Jane had neither pursued hormone therapy or any kind of body modification. She no longer construed what she needed to do in terms of transitioning. I say this descriptively and not as an indicator of a successful outcome as I do not consider that there is a pre-determined aim to therapy with transgendered individuals. However, in this particular case, I did consider that Jane’s label “trans” was the only way she could begin to explore conflicts that were only very partially related to gender identity as such. Changing her body in radical ways would not have addressed her deeper anxieties.

Jane’s eventual curiosity about why her biological mother might have given her up for adoption helped us to explore some of the fantasies about her adoption and how this related to her longstanding confusion about her identity, her so-called substance. This had become rigidly resolved by a retreat into certainty about being in the wrong body. Being a boy, as she explored and experimented with in her online life (and to a lesser extent in her day-to-day life through her altered physical appearance), allowed Jane to anchor herself in a body that felt more substantial with all the associated fantasies that as a boy she would have been wanted by her biological mother and that she would be taken seriously. The work with Jane required us to understand how her given girl body was felt by her to be the cause of her rejection by her birth mother such that the wished for male body was experienced unconsciously as securing the love of an idealised mother who would never give up her beautiful male baby.

Although Jane’s story and outcome are unique to her, the way that transgender identity served the function of binding anxiety largely unconnected to gender is not. Jane’s trans identity felt somewhat “off-the-shelf”: no less urgent or meaningful, and surely to be taken seriously, but not the culmination of a struggle in a sexed body that felt misaligned with her felt to be gender identity. Gender was relevant in so far as it was linked in her mind with the experience of rejection and the phantasy that a changed body would reverse this injury. The way she was managing this disturbing internal experience was to label this “trans” so as to make it tangible in a form that was communicable to others and that secured support and validation. But, we do well to wonder, what might have happened if Jane had just been validated by the transgender community or been to see a therapist who only mirrored what she felt without engaging her in making sense of why she felt this way (that is, not just “how” she felt).

Developmental causal accounts of human behaviour have traditionally been used to “bolster the usual binaries in mental health: normal abnormal, straight/perverse, healthy/sick” (Wren 2014, p. 282). This is evidently a risk we need to be alert to. However a developmental account need not be used in this way: it can help to provide yet another perspective from which to evaluate personal decisions that may be, at least in part, driven by earlier experiences that have not been reflected upon.

For example, Jane helped me to understand that her male avatar’s virtual physicality – and her actual attempts to look more masculine – literally gave her an embodied experience of her desire, fantasies and ghosts. I invoke the word “ghosts” because I have in mind here the boy she felt she should have been in order to secure her biological mother’s desire, which as we came to understand it was a very powerful motivator for the desired body modification. These ghosts needed to also be given narrative substance in the analytic exchange between us so that her decisions going forwards were less likely to be driven by their shadowy presence at the core of her embodied experience.

Another striking example of embodied “ghosts” was that of another of my young FtM – (female to male) – patients, Alex, who was determined (with some urgency) to proceed with full SRS. Alex identified as transgender for the first time aged 16. His parents had accepted his new identity without any questioning or affective reaction. This was in itself interesting. They were keen for him to be supported through the transitioning process as he had been feeling very anxious since he had come out as transgender, hence the referral to me.

I first met Alex aged 17 and shortly thereafter, supported by his parents, Alex started hormone treatment and then underwent a mastectomy abroad aged 19. My attempts to engage Alex in reflecting on these big decisions were not successful. Alex was determined to transition but he was equally determined to stay in therapy and this I considered to be very significant.

Early on in our work Alex made reference to a history of sexual abuse around the age of 10, which he had never told his parents about. There had been no interest at that point in reflecting on this as having any bearing on the decision to transition to a male body. For reasons of confidentiality I cannot give further details. Suffice to say that it was only after an all too brief “happy” initial period post-surgery that Alex became severely depressed and suicidal and said that he felt like he had lost all sexual desire. At this stage, he returned to this complex history of sexual abuse, at first via a series of dreams. Only then were we able to slowly make some connections between the wish to remove the breasts and the events in childhood. It became clear as the work progressed that Alex had been driven to cut himself off, quite literally, from the breasts that were concretely identified with a hated, shameful part of him. This realisation did not lead Alex to regret his decision to have a mastectomy, at this stage in his life at least. He said that he felt better even so, but it did help him to realise that he could not change the past or his feelings by changing his body.

A note on the counterstransference

Working in this area poses many challenges for the analyst, not least countertransferentially. Modifications to the body (some irreversible) at a young age can be emotionally arousing for the analyst and this has to be managed internally. In my work with Jane and other young people in her predicament, I have repeatedly noted a pressure to “act” that the patient brings because they feel they must change their body in order to feel better. Their desperation is poignant and they sometimes feel very suicidal. In turn this pressure can lead the analyst to interpret unconscious meaning prematurely (thereby also “acting”) in an attempt to “press pause” in the accelerated, and sometimes quite manic, process of seeking medical intervention. This can then leave the patient feeling that the analyst does not believe their experience of their body and does not support what they feel they need to do in order to feel better.

Jane was often angry at first when I tried to engage her in reflecting about meaning. In this particular case, I was mindful of how I had to struggle with my own view that it was not in Jane’s best interests to commence any kind of medical intervention, and the need to understand that this was quite the opposite of her own view on the matter. The only intervention that worked was to invite Jane to help me to understand her predicament better whilst repeatedly acknowledging the tensions that existed between us. That was the only “truth” that made sense to her: I did not understand her and it was indeed hard for her to come to see someone whom she felt did not share her agenda. This much we could agree on. But as the work progressed there were also times when it was helpful to her to hear that I had a different view as long as this view was shared with her not as “the truth” about her predicament, but simply as my understanding of her at that point, which might or might not be helpful. It was important to “mark” my interventions in this manner so as to communicate clearly that this was my perspective and not necessarily the last word on the matter.

In order to hold with integrity the position that I am advocating here, and hence to manage one’s own countertransference, the analyst requires actual experience of working with a reasonable number of transgendered patients so as to appreciate the spectrum of meanings of a transgender identification and its longer term outcomes. As I have been suggesting in this paper, it is a mistake to assume that there is one homogenous group of transgendered individuals to whom we can apply a single theory. This is why it is helpful for the analyst – even essential, I would argue – if the analyst has also worked with individuals who have transitioned and made a good-enough adaptation post-operatively. This broader perspective helps the analyst to manage what can otherwise become a potentially biased internal position, viewing any kind of transitioning as an indicator of “pathology”. This experience gives greater confidence to trust one’s own countertransference when faced with the intensity of feelings generated in this kind of work.

There is often also the need to manage what can be an intense countertransference resulting from the projections into the body of the analyst – a body that can be experienced by the patient as enviously appropriating what the patient desperately longs for. This was not a striking feature of my work with Jane but it is not uncommon, for example, when working as a woman with male-to-female transgendered patients. Such is the pain associated with the perceived difference that any difference is then obliterated, as happened with one of my patients, for example, who was convinced that I was also a transsexual.

Focusing on the body

Jane and Alex are representative of a sub-set of young transgendered people who are performing, as I suggested at the outset, a kind of “psychic surgery” through their stated wish to transition. Their difficulties, I am suggesting, reflect the self’s disturbed relationship to the body and its unconscious identifications.

We are born a body and we have to become one (Winnicott [1970] 2010). The body is more than a modality for expressing the self: it is where I exist (Milon 2005). It is the site of contest over identity, over what it means to be a subject. The body in the world is both foreground and background. It constitutes our locus, so that we are “here” rather than “there”. Crucially movement always displaces the self thus preventing it from coinciding with itself: there is always an “elsewhere”, a point that is “not where I am now” and hence “other”, an other I need or desire, an other who is not within my reach or control. The body is thus first and foremost my body even if it will always also be the site where otherness is located.

The notion of embodied alterity reminds us of the fundamental opacity of the other that is at the core of our embodied experience (Lemma 2010). The unfathomability or inaccessibility of the other resides under the skin, as it were. When we manipulate our embodied experience, and hence the representation of our bodies in our minds, say via virtual technologies (Lemma 2017), or by modifying the surface of our bodies via cosmetic surgery or tattoos, and as I have suggested here in some cases of transgender body modification too, we may be searching for more or less adaptive ways of managing the otherness inscribed in our bodies. This “otherness” has to be somehow integrated into our sense of who we are, into our identity. This is not an argument for or against surgery. The decision to have surgery per se is not in my view an indicator of pathology. The pursuit of any kind of body modification cannot be held in isolation to be an indicator of pathology. Rather the key issue is what states of mind underpin its pursuit (Amir 2018).

Some analysts view transgender as a “creative act” (a “sinthome”) and not as pathology (see Gherovici 2017; Gozlan’s, 2018 edited collection of essays). In a similar vein, Saketopoulou cautions against overlooking:

… how these repetitive embodied sexual scripts are being executed not as an acting out of self-destructive fantasy but as attempts to form new representations, to translate in novel ways an array of previously unrepresented sexual and gendered permutations. (2017, p. 1042)

These perspectives add an important voice to the debate. However, it remains our ethical responsibility to help our patients to also consider that even so-called creative acts come at significant costs and have multi-layered meanings that are not immediately accessible to our consciousness and that this requires processing (i.e. time) in order to make informed choices.

Perelberg (2019) rightly cautions against the “confusion of registers” that can ensnare both the transgender patient and the analyst such that they may both address “as real something that belongs to the symbolic sphere” (p. 45). But if open conversations can be allowed, if the analyst can sustain an equidistant curiosity – equidistant that is from whether modifying the body is a sign of pathology or a creative act – and the body as symbol can be considered, it may be that even if the modification of the body is eventually pursued, this will be based on a more solid integration between internal and external realities. I can think of several young people who have fully transitioned during our work, who have done so more aware of the drivers for this decision and for whom this has probably been, on balance, the better compromise.

In our contemporary culture the body is seen as pliable and open to redesign – a kind of project (Giddens 1991). This external context sets the frame for an identity label like “trans” to provide, for some people, a ready-made explanation and pathway for resolving a deeper unease or trauma that is located in the body. In these cases, the phantasy is that changing the body will erase the psychic pain. Of course, we need to be mindful when we work in this area that it is by no means easy to distinguish “‘psychodynamic’ suffering from the transphobic ‘cultural suffering’ caused by stigma, fear, hatred” (Goldner, quoted in Rose 2016, p. 11). But precisely because this is difficult, and because the pressure for the individual understandably is to relieve pain, inserting time to reflect into the decision-making process is of the essence. This is especially prescient during adolescence when the body, even when all is going well in development, is for most young people, to varying degrees, a source of turmoil and anxiety, and the pressure to act rather than to reflect is accentuated. One of the most striking contradictions when working in the area of transgender is that the conscious rhetoric about gender fluidity and the refusal to be tied down to prescriptive gender roles, in a number of cases, is undermined by the urgent need to find certainty about gender identity through enduring modifications of the body.

My work in this area repeatedly confirms for me that,

The plight of the transsexual exposes in possibly the most extreme manner the developmental challenge we all have to negotiate and to which we all find compromise solutions, namely how to transform the body one has into the body one is, or, to use a Winnicottian (1970) term, how to “personalize” it. (Lemma 2013, p. 279)

There are no shortcuts for any of us to the disturbing and painful psychic work necessary to secure a sustaining dwelling for the psyche in the body. This challenge is an arduous one that we keep revisiting at different life stages or when the body is compromised somehow, by illness or disability, or changed by pregnancy or ageing, for example. It is therefore not a once and for all process and it certainly requires time to get our minds round the meanings and implications of our embodied nature.

The starting point in my work in this area is the value of recognising that the “given” body is important psychically. This is because there is a double meaning to the notion of the “given” body, that is it refers both to the sexed body we are born into and the body “given” to us de facto by our parents linking us indelibly to them irrespective of any changes we subsequently make to the given body. Extensive modification of the body has an impact on the “temporal link” (Lemma 2016) that is an important feature of our identity as it provides continuity between different representations of the self over time (Grinberg and Grinberg 1981).

The experience of time is rooted both in the body’s potential for change and in its facticity. This highlights that it is not only change that has to be managed at the level of one’s bodily representation, for example, because of the changes brought on by puberty or by ageing or SRS, but also the continuity of the given body and the objects it inevitably ties us to. This continuity overrides any actual changes the body may undergo over time because the continuity I have in mind here relates to the given body’s link with the past and its origins.

We can change the appearance of the body in extensive ways, but if the unconscious impetus for this modification is in order to delete the imprint of the other as it is experienced in the body, surgery does not bring with it greater cohesion and relief; it triggers breakdown. Successful post-surgery adaptation is associated, in my experience, with the individual’s capacity to relate to their “new” edited body as always a reconstructed body with a history. This is the area that requires considerable and painful psychic work. We can add breasts where there were once none, we can take away a penis where there was once one, but it is impossible to obtain the original genitalia of the opposite sex. The acquired genital, and hence the “new” body, is always in the wake of a body that once was. This has nothing to do with whether the pursuit of a different body is healthy or not, if this is “right” or “wrong”. It is about recognising how we relate to the given body and what it means to us in the unconscious. It also has a bearing on the psychic importance of tolerating the fact of sexual difference which is an “organising principle” (Perelberg 2018) and, as Kohon reminds us,

this requires us to understand the complexity of gender that cannot be reduced either to a social construction or to biological differences (Kohon 2018).

The extent to which the temporal link can be maintained between the given body that once was and the post-modification body that replaces it makes a significant difference to post-operative adjustment. Pursuing surgery may be the only way to live, but the state of mind one has in relation to the body modifications and what they can deliver is crucial to the quality of relationships the individual can then establish through the newly reconstructed body.

Conclusions

Transgender has become one of the most controversial social and cultural issues of our time. As we a grapple with it in ourselves and in our practices we are confronted with how the body, sexuality and gender plunge us in the realm of experiences that may well be unsymbolisable.

The whole question of transgender is now salient in the media. The rate of publications on this subject is staggering. The Internet has facilitated a marked acceleration in the information available about transgender issues and the associated activism. The recognition of transgender experience has made it possible for people to feel less ashamed and isolated. Many of the young people I see point to information they found on the Internet that allowed them to finally self-diagnose the nature of their distress and find solutions to it by transitioning. If the Internet could be said to have increased the visibility of the transgender issue and reduced shame, it does not nevertheless guarantee recognition of the idiosyncratic ways in which transgender is subjectively lived in specific bodies with particular histories. Being visible is not the same as being seen but nowadays these processes have become unhelpfully conflated.

In this paper, I have advocated a more developmental approach. I am mindful that this kind of model serves a performative as well as a descriptive function (Wren 2014), with the attendant risk that it implicitly reinforces established gender norms. Neither am I oblivious to how my own so-called identity category as a “cis-gender” woman has no more certainty than the transgender one. As Rose soberly reminds us:

The bar of sexual difference is ruthless but that doesn’t mean that those who believe they subscribe to its law have any more idea of what is going on beneath the surface than the one who submits less willingly. For psychoanalysis, it is axiomatic, however clear you are in your own mind about being a man or a woman, that the unconscious knows better. (Rose 2016)

My experiential and theoretical reference points are steeped in conventional gender ideas. The grids of intelligibility that frame subjective experience inevitably limit every author, which is precisely why dialogue with others is vital so that we can ensure that we understand the different meanings of transgender identity and do justice to the heterogeneity of experience within the transgender community. Only this way can we assist more effectively those who seek our help. This will include those individuals for whom SRS is the chosen way forwards as well as those for whom this is unlikely to provide a solution. If ever we needed a range of evidence to help us to do best by our patients, it is in this area so as to ensure that prejudice does not overshadow the complexity and variation that belies a unifying identity label.

Psychoanalysis has an invidious history in relation to the prejudiced stance it took with respect to homosexuality and we must be careful not to repeat mistakes of the past when we approach transgender. Psychoanalysis should never be used as a tool of coercion or conversion – however subtle – when it comes to individual choices about how to live one’s life. That is not the role of the psychoanalyst. However, dialogue is a multi-way process and requires us all to tolerate many voices with a respect for the differences that this will expose.

When it comes to transgender discourse we cannot escape the fact that the idea of dialogue, which presupposes that that there is not “one” truth and that there may be several questions and different answers, is experienced by some transgender activists as “hate speech” that must be silenced (Janice Turner, The Times, 14/04/2018). Silencing, however, never pays dividends. If political correctness provides any corrective, this can only be surface deep. The policing of discourse runs the risk of atrophying thinking and consolidating prejudice rather than exposing it. However trying to understand the meaning and function of any behaviour, thought or feeling is not inherently an act of violence or oppression: at its best it is the everyday work of psychoanalysis.

Notes

1 I am not concerned here with those young transgendered people who seek non-medical ways to express the specificity of their gender identity.

2 Whereas the term “transsexual” often refers to trans men or trans women who physically transition to bring their bodies more into alignment with their felt to be gender identity, “transgender” identity is not dependent upon altering one’s body with hormones or surgery. Underpinning both identity terms is the sense of a movement across a socially imposed boundary from a “given” starting place to a place that is felt to be of one’s choosing.

3 Inserting time into the process is important not least because research suggests that between 73% and 88% of children attending gender identity clinics who present pre-pubertally, whether they have socially transitioned or not, are likely not to continue with their intention of changing their gender once puberty has started (Wallien and Cohen-Kettenis 2008).

4 For example, one study shows that psychological support and puberty suppression were both associated with an improved global psychosocial functioning in adolescents with GD (Costa et al. 2015).

5 “[When] it comes to the origin of sexual identity,” Ken Corbett wrote in 2009, “I am willing to live with not knowing. Indeed, I believe in not knowing … [I am not interested in] the ill-conceived aetiological question of ‘Why’ [someone is homosexual], I am interested in how someone is homosexual.” This stance is now being applied to the question of transgender.

6 Some people feel it is more acceptable to identify as transgender than homosexual, and this was on my mind as I listened to Jane. A risk is that in being “liberal” about transgender, one neglects the impact of internalised homophobia.

7 In fact as I was seeing Jane privately, and not as part of a gender identity service, my opinion was totally unconnected to Jane’s ability to access medical interventions: I was not involved in any decision making at a service level and would not be asked for a report.