Background
Alex is a 16 year old natal female with a diagnosis of Gender Dysphoria. I will refer to Alex as ‘he’ as he is known as male within his family and at school. He has made a social transition and he has changed his birth name from Eloise to Alex by deed poll approximately one year ago. He lives at home with his parents and an older brother who is at university. Parents are baffled by Alex’s cross gender identification and hold a sceptical stance, although they have been willing to address him by his chosen name and pronouns, as this has brought Alex significant relief and improvement in general functioning.
Alex is an androgynous looking young person of slender build, with diaphanous skin and delicate features. He ‘passes’, meaning his looks, at superficial glance, do not betray his biological sex, although his mannerism is rather feminine. He has been wearing a binder to compress his chest since the age of 14. Upon meeting him for the first time, he could easily be perceived as a rather effeminate, shy, young boy in his early teens on the cusp of puberty.
Alex and his family have chosen not to intervene to halt his female pubertal development with the prescription of hormone blockers as one of the side effects could be a lowering of mood and energy. Alex could, after the age of 18, be prescribed testosterone if he continues to meet criteria of Gender Dysphoria and he chooses to access physical intervention. Alex has been suffering for years from ‘fatigue’, disrupted sleep, anxiety, eating difficulties, superficial self-harm and mild OCD symptoms.
He is a very bright student at a high achieving all-girls school. Despite missing significant periods of school due to his ‘fatigue’ he has secured a place in the Sixth Form by gaining the highest grades in his GCSEs. Alex does not have any male friends and he socialises exclusively with girls from his school.
Alex has engaged well in his psychotherapy sessions, he is very forthcoming and values his sessions which started last autumn. Attendance has not been regular since Easter due to his school exams and school life which have dominated the narrative in the past few months. Gender feelings have occasionally featured in the sessions, but primarily in relation to his upset at the occasional mis-gendering. Just recently, themes loosely relating to gender have begun to feature in our sessions, together with a less rigid stance about ‘trans-issues’ that seems to indicate a growing capacity to tolerate exploration of meaning.
Session
This is the first session since a four week summer break – I was on leave for two weeks, Alex himself away due to family holidays for four weeks. In addition the sessions had been somewhat irregular since the previous Easter break, we had not had the opportunity to meet for more than two weeks in a row because of Alex’s studies and exams – work experience and other events in his calendar.
We both looked tanned. Alex looked very relaxed and at ease as he settled in the armchair crossing one leg under his other extended leg in a stance he describes as ‘masculine’. He did not hesitate to begin by saying that it had been a long time since we last met and that he had been on holidays twice noting how it felt like ‘ages’ since we last met. He briefly interspersed his narrative with his usual nervous giggles as he told me he had been to the US with school and to Italy with his family and two of his friends. I noted how it was also apparent I had been away too; Alex seemed to interpret this as an invitation to ask me about my break as he suddenly, very seriously, asked me where I had been on holiday. I felt stunned by the unusual immediacy of his question and, put on the spot, I chose to answer, feeling it might be helpful to further the conversation.
Reassured by my response he continued talking, telling me exactly where he went and how he had been pleased to have two friends with him and not just be with his parents and older brother. It had been different and ‘really fun’. He added that his family sometimes does not ‘sympathise’ with him and it is therefore nice to have friends with him. I clarified that he perhaps meant it is reassuring to have someone on his side and he agreed, adding that, although his parents can be relaxed about most things, they sometimes ‘loose it on random things’.
He told me about an ‘incident’ whilst they were away. Alex, his friends and family went to a remote beach; Alex was ‘fatigued’ on that day and Dad, without being asked to, had been carrying two beach umbrellas. Once they reached the beach, Alex and friends settled on one side of the beach whilst his family settled on the opposite side. Alex suggested Dad could meet him half way to give him one of the umbrellas. Dad ‘lost it’ and shouted at Alex for expecting him to bring the beach umbrella half way. Both Alex and his friends had been shocked by the reaction and they all felt there was no need for such a response, especially considering Alex was having a ‘real bad day physically’. As he continued talking, with a growing sense of righteousness and slightly amused outrage, he told me of another ‘incident’ when his brother had suffered from stomach pain after eating ice-cream. Both parents agreed this could be because of lactose intolerance and felt ‘sympathetic’ towards the brother. Alex lamented, with his usual half amused tone, that he himself had had to suffer ten years’ of stomach pains before his parents took him seriously and took him to the doctor, who finally diagnosed him with lactose intolerance. Alex had the boldness to remind parents of this as they attended to his ice-cream loving brother and this had prompted father to ‘proper shout’ at Alex, leaving him and his friends, who witnessed it all, baffled and slightly shocked. Alex spoke of how annoyed he feels when Dad shuts him down in such a way.
I acknowledged how both incidents related to him and Dad and noted how – unlike other times – Alex had been brought to the clinic by Dad today, something quite unusual. He explained that Mum was at work and Dad ‘had to take me’. I commented on his choice of words, implying perhaps this might have been a chore for Dad? Alex told me his Dad does not enjoy driving unlike Mum. Alex added that he feels more comfortable with Mum as, although she ‘does angry’ in a more passive aggressive way, she does not actually shout or lose her temper. I also noted how ordinarily, when I meet Alex in the waiting room, him and mother are sitting close to each other and engaged in conversation. Today Alex was sitting in a corner looking at his phone whilst Dad was by the window looking out. Alex giggled as he told me that although he shares interests with Dad they only ‘banter’, and they do not have deep conversations as he does not feel comfortable talking to him. I wondered whether he was saying that he can indeed ‘deal’ with passive aggressiveness but that he struggles when he is on the receiving end of shouting. He agreed adding that his mother is better at staying calm and at explaining the reason for her being angry.
He continued by saying that he hates conflict and that whenever someone shouts at him he finds it difficult to stay composed and very often he ends up crying. This, he said, has always been the case, both with teachers and with dad, to whom he feels he cannot put forward any kind of argument without crying. I noted how he was describing situations where, when faced with a shouting and angry authority figure, it becomes difficult for him to stay in touch with his ability to think and to ‘argue’. Alex agreed, adding that whenever he is shouted at “My inner thoughts take the side of whoever shouts at me” and he then thinks of himself as being an ‘idiot’. I commented on a part of him that perhaps very quickly identifies with a belittling, shouting, angry part, so much so he could be left struggling to think and whimpering. He quickly nodded and added “It turns my thoughts aggressive and angry towards myself.” Something, I noted, that may feel almost like a double whammy of shouting, the external shouter and the internal one, almost too much to bear?
Alex then spoke with some frustration about how he would like to be able to talk back at these sorts of times, and to explain why he did certain things in a particular way, but he feels too insecure and shuts down. He spoke animatedly of how he would like to be able to explain but “Part of me forbids me from giving the explanation.” Alex continued, telling me how this had got better since his early teens but after coming out as ‘trans’ it has become much easier, even though sometimes it is still a problem. I reflected on how, perhaps, coming out as trans has given him more of a narrative about what he has been calling his ‘problems’ in a way that maybe does not require much explanation. He agreed and added that before coming out as trans he would have to explain and engage in conversation in relation to his anxiety and his ‘problems’. He had been offered therapy sessions for his ‘problems’ which he dutifully attended but nothing helped. Once he came out, though, people became more understanding and able to make the links between his ‘problems’ and being trans. I commented on how this was also quite a powerful position to be in as the communication could also be perceived as saying ‘Don’t challenge me and my problems, my anxieties, because I am trans!’
Alex laughed as I continued by noting how this position also paradoxically shuts down the very thinking he would so much like to stay in touch with and perhaps also further isolates him. He nodded in agreement, with a distinct change of mood, now looking quite serious. I wondered whether hiding ‘his problems’ behind the trans narrative made a very vulnerable part of him somehow feel safer. He nodded once more, but then seemed to be dismissing this idea with a laugh as he said that he very often jokes about it (being trans).
He then spoke of how, since coming out, his life has been easier as he can talk to people and people can ‘see me more as I am’. Alex continued that he feels that much of his previous anxiety was related to him ‘bottling his gender feelings up’ and since coming out it has been like lifting a massive weight off his chest and he now feels much freer when talking. Before coming out, he would have to explain things about himself, to try and communicate something about himself when actually it was ‘just about being trans’. I referred to that part of him he had described as pairing up and joining in with the shouting and belittling, and I wondered about the more vulnerable and fragile part, whether perhaps identifying as trans helped with giving this more vulnerable part legitimacy and a ‘propping up’ or ‘bolstering up’, as well as the benefit of not needing to give ‘explanations’. Alex agreed, and described naming being trans as an ‘umbrella explanation’ that has the effect of shutting people down, and that also, once a person comes out as trans, then there are lots of people behind you (he was referring to trans activists). He half-jokingly told me how useful it is that school is ‘scared’ about being transphobic. Perhaps feeling that he was steering away from the internal ‘benefits’ for him, I repeated my comment on how it also gave legitimacy to his feelings of hurt and vulnerability, fragility and anxiety, not unlike his diagnosis relating to his food intolerances.
Alex noted how his parents can sometimes call his ‘bluff’ – meaning when they challenge him that he cannot always just attribute things to being trans – although they are quite cautious about this. I commented on how perhaps his parents, and perhaps also me and even the service itself to some degree, have to be careful so as not to ‘tip things over’. Alex agreed, with some humour, that it feels as he said that he is indeed a very sensitive person and that Dad should understand that he has a lot going on and Dad just cannot keep on adding on to it by getting angry at random things! I noted how perhaps Dad felt as if he could not be angry at Alex for the ‘trans related things’, for fear of rattling things up and tipping things over and maybe his getting angry at ‘random things’ felt safer for all of them.
Alex looked pensive and told me how Dad is too harsh and ‘nags’ him when some days he really cannot even get out of bed and even small things such as brushing his teeth are an achievement. He spoke with some anger of how Dad is good at shouting but not at giving praise for his small achievements. Alex had tried to talk to him and has asked mum to talk to him but things do not seem to change. I noted how this theme of difficult three-way communication, who is on whose side, had come up just before the holidays. Alex took this up immediately and updated me on the situation between him and his two friends telling me that Sam is still angry with him as he, Alex, has IBS and Sam thinks he is lying. He spoke of the legitimacy of his own diagnosis as opposed to Sam, who is just on a trial diet. Sam, Alex told me, often tries to catch him out whenever he eats from the list of foods he should not be eating. I said that he seemed to be describing Sam as being the kind of figure who tries to ‘call his bluff’ … Alex responded with an inflated sense of righteousness, agreeing with my comment and also asking why Sam cares so much about what he eats. He then added that Sam herself is now being referred to CAMHS as she too may have mental health problems.
I noted how we were talking about mind and body, what is physical and what is related to the mind and commented on how perhaps there is pull towards finding a medical solution – such as hormones – which, interestingly, does validate the issue as a medical one, instead of perhaps trying to find added layers of meaning without necessarily intervening medically. Alex paused pensively before saying “Yes, it is confusing” adding that the people who research it do not know how it feels. I noted how there is no actual physical test that can certify the diagnosis of Gender Dysphoria but perhaps taking things gradually, such as beginning with living in role, is a bit like the diet of elimination he spoke about before.
Alex went on to tell me that he had lived as male on the internet for a while before he spoke to people about it and that this was when he was ‘happiest’. It was then, having liked it, that he decided he wanted to do it for the rest of his life and came out. Living as male in the virtual world and being happy made him realise that he had been unhappy because people were relating to him as female in real life and he wanted to change that. I spoke of Alex creating himself as Alex. Alex responded that it was like ‘becoming my real self’. When he was sad he was not really himself. On the net he was more comfortable ‘being me’ and talking ‘as me’: “I felt better. I want this for the rest of my life – I don’t want to try to be someone else” (female).
He then spoke of how in the first years of secondary school he tried to fit in and it did not work out. He tried liking same things as everyone but it was a ‘dark time’ in his life; he then found some very good friends who liked the same things he liked and realised he does not have to ‘be normal’ – and now no one thinks he is weird because he is a guy. Everyone thought he was really gay, really butch – but because now he is a guy it feels more ‘normal’. He spoke of himself as being ‘stereotypically a masculine person’ and how this was perceived as weird by those around him. 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. I then gently took up with him how although we had just been talking about Alex being happier, more confident, more accepted perhaps there were still his ‘problems’ and I reminded him of how, before the holidays, he had just very cautiously begun to talk about his self-harm and late night worries. I asked how he had managed during the holidays and he told me that although he had had some urges to cut he had resisted this but ‘the thoughts are still there’. I realised it was now time to end the session and, in what felt like a rather hurried way without leaving enough time to pause on what he had just said, I acknowledged we had just touched on something quite important that may be helpful to re-visit at our next appointment and ended the session.
https://doi.org/10.1080/0075417X.2018.1414866