‘Un-certainty’: working therapeutically with a transgender young person and learning to bear the unknown

Abstract

The rate of referrals to mental health services for children and young people for whom gender dysphoria is the identified clinical issue has increased significantly over the last ten years. Debates around the classifications of gender identity disorder, gender dysphoria or gender incongruence, as well as the involvement of child and adolescent mental health services with this group of children and young people seem to be re-enacting the societal gender binary world view where we see acceptance versus rejection, open-mindedness versus conservative, trans-phobic thinking. In this paper the author will attempt to shed some light on the work with these young people in a clinical setting by reflecting on a year of therapeutic work with a female to male young person. Through the therapist’s reflections upon these binary preconceptions, along with the use of developmental and object relations theory, an in-depth account of the work is given. It is suggested that in some cases the therapist’s capacity to bear the unknown, while gradually observing and mirroring the un-integrated inner self of the patient, can gradually bring the fragments together, even if not in a perfect fit, and that this in turn provides a sense of relief.

Keywords:

• Psychoanalytic psychotherapy
• adolescence
• gender dysphoria
• transgender

Acknowledgements

I would firstly like to express my gratitude to Alex for granting permission for the publication of clinical material. I would also like to thank my Service Supervisors, Miranda Passey and Lara Bracher for their invaluable guidance and support. In addition, I would like to acknowledge my appreciation of all the members and trainees of the IPCAPA for stimulating my thinking and supporting me; a special thank you to Monica Lanyado for her insightful and helpful comments on this paper. Many thanks also go to Jo Russell, who has been the editor of this paper. Last but not least I would like to thank my analyst for the enduring support.

Notes

1. The classification of ‘gender identity disorder’, listed for both DSM-IV and ICD-10, or ‘gender dysphoria in children’, as re-classified in DSM-V, and ‘gender incongruence’, described in the December 2016 draft of the ICD-11, is used with reference to children/young people who present with atypical gender identity development features. More specifically, children/young people grouped under this classification are characterised by strong and persistent cross-gender identification (such as stating a desire to be the other sex or frequently passing as the other sex) coupled with persistent discomfort with the assigned sex (manifested for example as a preoccupation with altering primary and secondary sex characteristics through hormonal manipulation or surgery).