Alex, aged 16, visits his psychotherapist. They discuss his relationship with his parents and friends. Alex identifies as trans and has worn a binder since age 14, but has, with his parents, chosen not to use puberty blockers as they have the side effect of lowering mood and energy. He is a high-achieving student at an all-girls school, and could be perceived as a young, shy, effeminate boy just before puberty. He suffers with fatigue, disrupted sleep, anxiety, eating difficulties, superficial self harm and mild obsessive compulsive disorder symptoms.
Will he be encouraged to transition? Will his psychotherapist examine any underlying issues which might cause him to identify as trans? Online, I read the therapist’s account of the session, then clinical commentary by two psychotherapists: Amanda Keenan, child and adolescent psychotherapist, who trained at the Tavistock clinic, and Margaret Rustin, child and adolescent psychotherapist who was head of child psychotherapy at the Tavistock for 24 years. The Tavistock runs the English Gender Identity Development Service, as well as other services. There are also maunderings from disgraced psychotherapist Robert Withers, which are more revealing about himself than the case.
Before transition, everyone thought he was really gay, really butch, but he began living as male, at first on the internet, when he felt he was being himself. He felt better, and wanted this for the rest of his life. Accordingly he socially transitioned. He tells his therapist how he hates conflict, and when someone shouts at him “My inner thoughts take the side of whoever shouts at me”, and then he thinks of himself as an idiot. He would like to talk back, but part of him forbids him to.
His psychotherapist suggests that coming out as trans gives him a narrative about what causes his problems, and wonders if the trans narrative makes a vulnerable part of him feel safer. The narrative shuts others down, and it is useful that school is “scared” about being transphobic. The narrative legitimates his feelings of hurt, vulnerability, fragility and anxiety, and there are lots of people (trans activists) backing him up.
Alex agreed when the therapist suggested his belief that he is trans prevents him from being in touch with that vulnerable part. The therapist suggested trying to find layers of meaning without intervening hormonally. They suggested his trans identification gave legitimacy to his “weirdness”. Alex agreed. They agreed to revisit at the next session.
Alex suffered years of stomach pains before his parents took him seriously, and his doctor diagnosed him with lactose intolerance. He is angry that when his brother had stomach pain after eating ice cream his parents immediately believed the brother.
Amanda Keenan says Alex is trying to avoid and defend against the challenges of adolescence. Some adolescents overachieve academically as a way of avoiding emotional conflict. Alex’s intellectualisation, thinking about his difficulties, might get in the way of learning from emotional experience. She considers his eating difficulties reinforce her sense that he finds it hard to digest emotion. His friends are like a gang, there to support and defend each other. She wonders if “Alex unconsciously provokes others to shout at him in the service of punishing himself”.
She finds him strongly defended. She says he wants control, and fears being in touch with feeling. Keenan says the therapist is in a difficult position, either to be blamed like Alex’s father, or being forced to support him like his friends?
Margaret Rustin “suggests that the dissonance between Alex’s sense of himself as a person and the perception of others was very painful to him. He is relieved when he can assert his sense of reality in opposition to what others think they see.” He assumes his therapist will be on his side in his conflicts with father and friends. She might see his symptoms “as evidence of aggression turned against the self due to anxiety about expressing it in relationships”. She notes the privilege children can get from being ill, and needing parental attention or NHS care.
At the end of the session, “the therapist suddenly notes his deflated tiredness, signalling the failure of the manic solution which a masculine identity had seemed to offer him, and which is so seductive when separation looms… I would suggest that behind the choice of a masculine identity is anxiety about femininity seen by Alex as inferior, passive, weak and depressed. His intellect (clearly a powerful one) is by contrast experienced as a male aspect of himself, able to have a voice and a position and exist in its own right, not needy and dependent.”
I don’t know whether Alex is trans, or whether he will transition. However I note that he is not on puberty blockers, and that therapists associated with the Tavistock are questioning his trans identification, and keen to find explanations of it.
What about Withers’ witterings? They are more revealing of himself than of Alex. He writes, “In my own experience, working with people who use the trans narrative to distance themselves from feelings of vulnerability in this way can evoke hard to reach feelings of hatred in the countertransference.” Counter-transference is the therapist’s feeling. Withers reiterates his false claim that ethics might prevent a therapist from exploring what is underlying a trans identification, and cites his own paper.
The whole paper is publicly available. While the heading is “clinical commentary by Robert Withers”, the therapist’s account and Keenan’s and Rustin’s comments are included. I find it reassuring. Suggestions that children are forcibly transitioned are belied by the care of the three child psychotherapists. If Alex is trans I feel he will be supported in his transition. If she is not, I feel she will be helped to navigate the difficulties of adolescence.
Clare Flourish 