Is Alex trans?

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.

Robert Withers

Two trans people have had the misfortune to see Robert Withers, a psychotherapist, but he has set himself up as an “expert” in trans, to transphobes and anti-trans campaigners what Andrew Wakefield is to anti-vaxxers. If the quotes attributed to him on far-right hate-site Spiked are accurate, he has a remarkable lack of insight and self-knowledge for a psychotherapist. Perhaps the clinical supervision ordered by the UK Council for Psychotherapy discipline tribunal will help him work with his counter-transference onto trans people. After six months, the UKCP will assess a report by his supervisor and his own reflective piece summarising his learning from the supervision, and decide whether further sanction is necessary: not as a punishment, but to uphold proper standards of conduct and behaviour.

He has a lot to learn. Spiked quotes what the anti-vaxxers, sorry, anti-transers love: Withers’ equivalent of “vaccines cause autism”. Withers claims he could see a patient who identifies with the opposite gender, “work successfully on a patient’s mind, who is experiencing these feelings, and you reconcile him with his body and his past”. Amazing! With the experience of two patients, he claims to do what surely all psychiatrists and psychologists involved with trans people would want to do, if only it were possible. The reason they give hormones and surgery is that transition is the vaccine, as it were, which prevents gender dysphoria from being such a misery. However, Withers has never done this: his first trans patient had decided to revert, and Withers just went along with it, and his second trans patient made a complaint against him.

Withers says there is no such “thing as a male body with a female brain. But even saying that is considered transphobic”. He lacks self-knowledge. He is called transphobic because he is transphobic. It is true that there is no proof of a biological cause for “transgenderism”, but the proof trans people exist is trans people. The proof that transition is appropriate is the experience of tens or hundreds of thousands of trans people and the clinicians who have treated us.

Withers’ persecution complex comes out: he says if he managed to reconcile someone with their birth sex he could be struck off for conversion therapy. This is to misunderstand what conversion therapy is: it is an attempt to force a person to believe they are other than they are. Withers’ reading comprehension is clearly too low for a psychotherapist. He is scare-mongering about the Memorandum of Understanding of the NHS on conversion therapy, which states, “Some people may benefit from the challenge of psychotherapy and counselling to help them manage dysphoria and to clarify their sense of themselves. Clients make healthy choices when they understand themselves better.”

The anti-trans campaigners love Withers: he makes them feel vicariously persecuted. They want to feel, as with any conspiracy theory, that they are a small minority who alone know the truth.

“It is difficult to get a man to understand something, when his income depends on his not understanding it.” Addressing the mental health issues of trans people, even possible causes for them saying they are trans, is permitted. A therapist who, from a closed mind, pretends there is some cause which, when understood, can make transgender ideation melt away, and devotes his time with his patient to finding evidence of such a cause, should be struck off.

Withers was so excited about his second trans patient that he did not ask her consent to refer to her case in his writings. She met with him and asked him to stop publishing about her, and he refused. He denied this before the discipline tribunal, but they found his evidence defensive, inconsistent, muddled and avoidant, transparently annoyed that her refusal of consent prevented him from publishing details. So they disbelieved him. This brave woman gave an account of her ordeal: “To have someone pour scorn over who you are”- in what was supposed to be therapy!- “is really destabilising”.

Having seen two patients, Withers is keen to share his “expertise”. For example, he gives “clinical commentary” on an account of therapy of a trans child. That page shows his article has zero citations- his peers see his value- but still he hawks his opinions about to the transphobes. In the paper he says that when working with his trans patient, the countertransference- the feelings evoked in him by the interaction- was “hatred”. I would not want to work with a psychotherapist who felt hatred in the sessions.

In that paper, Withers claims “Identifying as a ‘butch lesbian’ is not currently celebrated or socially affirmed.” There is a great deal of homophobia about, though there is more transphobia- The Times prints transphobia several times a week, homophobia more rarely. Not all trans children find affirming parents or schools, and if they can find others like themselves on line so can young lesbians. Despite all this, Withers suggests the patient might “drop his male identification” if he were affirmed as a lesbian.

Withers attempted to argue to the disciplinary panel that the code of conduct for psychotherapists is deficient, in that it should allow some interest in publication to override obligations of confidentiality, and attempted to call an expert witness to make that point. His witness was unable to turn up. The panel said that argument was not relevant. Withers’ arrogance before the panel, evident from their judgment, shows he would be a poor choice of psychotherapist. Perhaps like Wakefield he will end up making all his income from conspiracy theorists.

Here is the discipline tribunal decision: Robert Withers psychotherapist misconduct hearing.

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From Withers’ own words, a more serious case than mere breach of confidentiality might have been made in the discipline tribunal. Withers is quoted in Spiked as saying, of his trans client, “Half an hour after the session ended, [she] came back to my consulting room in a psychotic state. [She] had been out in the world and [she] thought people were going to attack [her]… For a moment, I caused [her] to doubt [her] identity, and [she] had a catastrophic collapse in [her] sense of who [she] was.” He indicates no remorse about this. By his own words, he had endangered his client, and she says he traumatised her. Withers is not a doctor, so is not qualified to diagnose, and the tribunal enumerated reasons to doubt his word, but by his own words he showed no understanding of his obligations to her. Is he truly fit to practise as a psychotherapist? Here are some links on harm that can be done by a bad psychotherapist: The Conversation, Psychology Today. As Psychscenehub says, “A therapist that prioritises his or her own needs (exploitative, narcissistic, voyeuristic) over the patient’s needs can do harm.”

Love, truth and trans

Love without truth is… It is such a tempting rhetorical formula that there have been several tries. Love without truth is sentimentality, hypocrisy, cowardly self-indulgence. Truth without love is either brutality, harshness or perhaps imperious self-righteousness. Evangelical Christians, who think Love may be tough, aimed at correction, not sparing the rod, might say Love needs grace as well as truth. The balance of love and truth is the conflict between liberal and conservative Christians, who emphasize one or the other.

Possibly over-influenced by the company I keep, I am nearly able to use the term the “trans cult” for trans theorists, in anger and blaming, but not quite. I am persuaded that humans are divided into two different sexes, but that gender is cultural. Patriarchy devalues some aspects of humanity and projects them onto women. Jung said the man must recognise his anima, the female soul within, and the woman her animus- for the qualities are not divided between feminine and masculine, but all human. The answer is to cherish the qualities of each individual. That is the minimum for love, respect, the I-Thou relationship treating all people as ends not means… there is no truth without love, for only love really sees.

Trans fits people in society as we are now. No, I am not a woman: I am a trans woman, a product of the culture, trying to find my way as best I can, find peace, find a place I might fit. Some people make a success of it: after a period of drifting they transition and make their way in the world. I don’t think it should involve surgery, perhaps not even hormone treatment. I see no point in surgery. It makes us infertile, and if it makes us more acceptable to others it is by proving we are sincere rather than proving we are women, or proving we have the doctors’ confirmation, which I don’t think we should need. Surgery seems the final stage of transition, the Holy Grail. It holds out hopes to at once make you a woman, win acceptance from others, and complete the transition journey. Your life will be wonderful. It is a thing to celebrate: we send each other cards marked “It’s a Girl!” Yet it’s still you with your same problems, and the problems of dilation and recovery from surgery as well.

While trans people have surgery, we will want surgery. Of course some of us will be able to make a go of life post-op, and some might even imagine it’s because of the op. But it does not do anything for you. A woman with a penis makes no sense, but me with a penis does. You are born in your own body. We will want surgery the more if we are aware of hostility in society, because we will want to prove ourselves. But genital surgery is only a symbol. If you want to wear a swimming costume or tight jeans, tuck.

Top surgery for trans men is quite different. It means you can stop binding- breathe freely, free of discomfort- and is essential for passing. I do not criticise any trans man for wanting top surgery.

Yet, we exist. Trying to live with my gifts and characteristics, I find presenting female more congenial. The qualities patriarchy devalues and projects onto women, I have. I have no wish to revert. I am a trans woman. So trans women should be treated and accepted as women.

That’s too subtle for many. If, as the Labour party asserts, trans women are women, we should be accepted and treated as women. If we are not, then we should not.

To avoid surgery and hormone treatment, trans women should be treated as women. We have transitioned. We are not dangerous, and should be treated as individuals, not blamed for each others’ wrongdoing.

Cross-dressing and gender queering should be welcomed, to subvert gender expectations, which harm both sexes. When someone wants to transition permanently they should be helped to value all that they are, for everything that is, is holy. Perhaps then transition will not seem necessary. This is the opposite of conversion therapy. The only problem with all this is feminism and the rights of women- and the wrongs women suffer from others.

Accepting Ourselves

The NHS and professional bodies are committed to ending the practice of conversion therapy in the UK. With “gay cures” it is clear that means attempts to make a gay person attracted to the opposite sex or not attracted to their own sex, but what does it mean for trans folk?

We self-diagnose. No-one goes to a doctor with a set of symptoms and is surprised to be told they have gender dysphoria: if you know of anyone, please tell me. We have contacted people in the community and reached an understanding of what we want. Possibly we have got hormones off the internet, or already transitioned.

Gay identity can be liberated. Battered down by the homophobia pervading society, a person can actualise their fully functioning human identity by therapy, accepting their attractions, using them to build relationship and community, and getting sexual release without shame. The whole person is good, right and acceptable. Self-acceptance empowers them to fulfil their goals and share their gifts in society.

Trans identity comes from a feeling of not fitting, not being congruent. My being, my personality, character, real me, inner self, conflicted and oppressed through internalised transphobia, are nevertheless right and beautiful and can be liberated by good psychotherapy working with my intense desire to know the truth, my human capacity for growth and healing, and my Love. But that misses out my body.

Bodies are embarrassing. We cover them with clothes, not just for warmth. They do embarrassing things like belch, fart, excrete, menstruate. They get sore and tired. We want them to be other than they are, so diet and exercise to change them, rather than for the joy of it. Encouraged by the culture, we imagine an ideal body and always feel we fall short of it.

My body is beautiful.
My body is acceptable.
My body is full of potential.

I can develop it, but should be careful when I imagine I should constrain it, and only do that for good reason. Here is Walt Whitman, section 20 of Song of Myself, worth glorying in for its shocking Acceptance:

I find no sweeter fat than sticks to my own bones.

In all people I see myself, none more and not one a barley-corn less,
And the good or bad I say of myself I say of them.

I know I am solid and sound,
To me the converging objects of the universe perpetually flow,
All are written to me, and I must get what the writing means.

I know I am deathless,
I know this orbit of mine cannot be swept by a carpenter’s compass,
I know I shall not pass like a child’s carlacue cut with a burnt stick at night.

I know I am august,
I do not trouble my spirit to vindicate itself or be understood,
I see that the elementary laws never apologize,
(I reckon I behave no prouder than the level I plant my house by, after all.)

I exist as I am, that is enough,
If no other in the world be aware I sit content,
And if each and all be aware I sit content.

One world is aware and by far the largest to me, and that is my- self,
And whether I come to my own to-day or in ten thousand or ten million years,
I can cheerfully take it now, or with equal cheerfulness I can wait.

My foothold is tenon’d and mortis’d in granite,
I laugh at what you call dissolution,
And I know the amplitude of time.

Is that not glorious? Read it again, breathe, glory in it. This- this creature, body, mind, spirit, brain, thews and sinews, questing intelligence, empathy, Love- is completely and entirely beautiful. My body is beautiful.

I only realised my body is beautiful after transition. My arm is beautiful: rounded, long and slim and strong enough, with a lovely, dextrous hand, and before transition I saw it as thin, weak and unmanly.

Something does not fit. What is it? There are three alternatives:

  • The soft, gentle, empathetic spirit
  • The body, with penis and testicles, precisely the size it is
  • The cultural understanding that a man should be like this and a woman should be like that.

We take into ourselves that cultural concept. First I tried to make a man of myself, to fit that concept, and then when I began to accept my spirit as it is I transitioned, so I could be that spirit-self and at the same time conform to the cultural understanding. My presentation, as a man, dressed as a man, did not fit, so I changed it; my body, with a man’s facial and body hair, penis and testicles, did not fit, so I changed that too.

The NHS wants to end conversion therapy, but what would preventing conversion therapy look like, when the culture does such a brilliant job of convincing us that we are wrong, inadequate, not as we ought to be? It gives us two courses, both of which involve converting us to fit in: make a man of yourself, or alter your body and express female. We start therapy converted, not accepting ourselves. Therapy addresses the mind, and helps us accept our spirit, but does not address the cultural rejection of the body. Unless  therapists take into account the conversion wrought by the culture, and oppose it, they are complicit with it. All of me is acceptable, just as it is, body as well as spirit.

The problem for me is that I don’t know if I could convince my 35 year old self, committed to transition, believing that was the way to accept and liberate my feminine self, and to give a clear impression of who I am so that others can interact comfortably with me and I with them. Clothes are so much of how you signal who you are. I always knew that I might be trying to live as a man five years after, but I had to get there via transition.

To accept my spirit, I had to transition, and spend years on it. I could accept my body if I saw it as female. I still best get a handle on my personality if I conceptualise it as “feminine”.  To accept my spirit and body together without transition might have been too much for me.

Trans identity

Some people are trans. How much of that is innate, and how much cultural? I say effeminate men might find transition attractive. Others say that people with the sexual orientation of autogynephilia transition- in that case I am bisexual between an autogynephilic orientation and a gynephile orientation, as I am attracted to women other than myself. The real world is more complex than theories can portray.

Others say the phenomenon is Trans, where female souls/brains/psyches in male bodies are only happy once transitioned, and children as young as three can experience bodily dysphoria, loathing their penises. This is the “trans ideology” so hated by the TERFs. If I am really a woman, of course I should be allowed in women’s space. I say I am sort-of culturally a woman, an anomaly, so should be tolerated in women’s space, because the majority of women so tolerate me, and because I am harmless and we are mostly harmless.

Or I could say that I am Different, so for the comfort of the Normal people I have to be shoved into a box, and when I could not tolerate the Man box the Transwoman box was the other one available. The goal of Diversity is that no-one should be shoved into a box.

Possibly what you want to do governs what you think about it. I wanted to transition, so I thought I was transsexual. And what your identity is affects what you do. I thought true transsexuals had sex reassignment surgery, so I had sex reassignment surgery. So there are different names for it, validating it- gender confirmation surgery is the latest I heard. Neovagina, says the surgeon, making it sound good. “Fxxk hole”, says the radical feminist, communicating her contempt.

This post about identity is written by someone who opposes transition. People approach medical services saying they are trans, and seeking medical reassignment. Their identity is that of a trans person. They believe they are a trans person, and that that means hormones and surgery. Lisa Marchiano wishes to treat gender dysphoria as a symptom, and explore with her patient what that symptom means. Gender dysphoria causes distress. The identity model says the person is trans, and the way to alleviate the distress is medical transition. Marchiano is against transition: it is a “drastic, permanent medical intervention”, leading to “permanent, life-long sterility 100% of the time”. One never reads in such articles that transition makes some people happier and higher-functioning, but it does. I would be happier if the writers admitted the value of transition for the patient in some cases.

She values self-identity. We tell ourselves stories about ourselves. I identify as Quaker, Scots, English, cultured. These things matter to me. The therapist accepting them empowers me. The therapist only challenges them if they lead to maladaptive behaviour. Yet how can I know myself? I identified the Real Me as female, but now identify it as feminine. I am a pansy. My self-identification often is changed by the words I use. I seek more accurate words. She says gender dysphoria does not mean necessarily that I am trans, but that the therapist needs to explore the meaning of the symptom and be open to what emerges. That she questions self-identity as trans does not mean she treats the symptom as unimportant or illusory.

She breaks down gender dysphoria into separate symptoms, including alienation from ones body. I hated the slimness of my arms, because it seemed weak and unmanly. Now I love my arms and hands, which I find beautiful. Finding a way to accept me as me, rather than accept aspects of my body because they fit “woman” and I identify as “trans woman”- accepting what is, and finding the good in it- would have been better than transitioning, if only I could have pulled it off. Teenage girls are alienated from their bodies by porn culture, and she says they decide transition is the answer due to a social contagion: it is the answer they find, and they latch onto it, then seek out evidence to confirm it, which they find in many sites providing mutual reassurance. (As do the radical feminists who decide we are monstrous then seek evidence and reassurance to confirm that.) I was homophobic and femmephobic- a man should not be feminine, I thought. It was not internalised transphobia, but femmephobia. How much better to relieve my self-loathing than to force me into the trans-woman box which I thought fitted my feminine self!

She says there are often other mental health conditions. One doctor said I had narcissistic personality traits, another denied it, and those traits might cause or be caused by the dysphoria, but finding a way of alleviating them might make the dysphoria less serious.

I see no evidence that she accepts transition as an appropriate course for anyone. She attacks “transgender ideology” as incoherent. She says there is no basis for a “gender identity” (her scare-quotes) that supersedes “objective biological sex”. This makes her assessment of research on outcomes suspect, though I doubt you would find an objective meta-analysis, untainted by any desire to affirm or deny transition as a treatment. Her reference to “a late-transitioning MtT autogynephile” links to Anne Lawrence. That is hostile. Here she writes that trans people exist, and should be protected; but she would rather manage gender dysphoria without transition. I feel her position has hardened further since. But I agree that we should explore the anima and animus, male and female, within ourselves.

I love her desire to explore deeply the sources of distress and seek varied possible solutions. That is not the NHS model, which favours quick fixes, even bodges. We would see the person in front of us in all of their miraculous complexity, and not just as a “gender identity,” she says. If only!

 

Psychotherapy for trans people

Is therapy completely worthless, or might it have some use?

Reparative therapy has always failed, because of how it envisages health, and what it attempts to do. Aversion therapy attempted to make the victim associate their desires with pain, fear, discomfort and misery. If the therapist, claiming that the person needs to control their desires, to fit in with normal society, prevented the person from acting on their desires, that would be a “success”.

For me, any organism seeks out its own health and good. Just as a broken bone knits together, so the mind turns towards what will fulfil it. People are different, with different gifts, and that fulfilment is different for each. The individual does not cross-dress because she is disgusting, and wants to be disgusting, as my mother said, but as the best way she knows of approaching health. The question would be, why does she cross-dress? What does it achieve for her?

The aim would not be to prevent the person dressing, but to find options for her. Is there another way of proceeding, which she prefers? The choice would still be the patient’s. Barry wrote of a person who transitioned role and was going to have surgery, but then reverted and found a partner.

You might favour transition if you imagine that men should be a certain way, women should be a different way. If men are generally more “masculine” whether this comes from nature or nurture or social construct, you may be more comfortable expressing yourself as a woman. Even if you don’t believe these restrictions are appropriate, you might observe that they exist, and feel you will be more accepted after transition.

Intensive psychotherapy would find your wounds and scars. What are you repressing? What shames you, what do you fear in yourself? We are a social species, and trans women in particular are intensely pro-social. We are made in the image of God, loving, creative, powerful, beautiful. What do you want from life? Again, the question is not “Why are you so broken that you contemplate transition?” It is “Who are you?” I have addressed this question after transition, as everyone must, some time.

norah-neilson-gray-little-brother

Graeme McGrath

Graeme McGrath, now retired, was an odd hybrid, a consultant psychotherapist: a physician working as a psychotherapist. He did not specialise in transsexuality, but dabbled, and three friends found him very helpful. I saw him in 1998, and that Autumn I got copies of the letters he had sent to my GP. I think the diagnosis accurate, though I hope I have grown beyond it now:

Mr Languish’s difficulties are related to a narcissistic personality structure. He is clearly unhappy and at times has felt despairing and, I suspect, suicidal. I am not sure formal psychotherapy is likely to help, and will require a direction and intensity of therapy which we cannot offer.

A month later:

His attitude throughout the interview was detached and somewhat ironic. It is increasingly clear that this functions as a very powerful defence against acknowledging the strength of his feelings. He briefly became extremely distressed, but when I tried to explore this he controlled himself very rapidly and returned to his normal way of interacting.

A further month:

Although he was keen to tell me about particular incidents when he had experienced intense feelings, I felt it was difficult to engage in any fruitful discussion of these. He tends to ruminate in a rather intellectual way and I thought his preoccupation with his own mental processes was part of his general difficulty in engaging with others rather than the kind of psychological reflection which leads to effective change.

I do not think exploratory psychotherapy has much to offer Mr Languish now. He is not transsexual, but his cross-dressing serves an important psychological function. Although he often feels extremely distressed and unhappy, I suspect that even if he were able to engage with the process of psychotherapy the threat to his defences may well make him feel much worse without necessarily leading to any effective change. He may well get something from a relatively non-intensive supportive relationship with someone who might be able to help him adapt to his chosen lifestyle. I suspect that this may well be available through the transgender network with which he is already in touch. I have not arranged to see him again and have discharged him from my care.

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A few years after I transitioned, I felt wary and alert in the tribunal waiting room in Manchester, and then realised: I had noticed a medical report another representative had, which happened to have Graeme McGrath’s letterhead. Those letters really got to me. I burned them and some other tranny papers in 2009.

His diagnosis is wrong: I am transsexual. I would not still be expressing myself female were I not. His diagnostic error comes from exalting the scientific “understanding” over the reality: some trans women are observed to have certain characteristics, therefore anyone without one or more of those characteristics is not a trans woman.

The personality issues: Yes, that is how I was. I am better able to relate to people now. I am more aware of my own feelings, and more self-accepting. I think they come from being female and forced into male role, and being intuitive and touchy-feely in a family where that was devalued in favour of control and rationalism.

I am going back to this now to see how I have ended up unemployed. It helps me understand. It helps me value my journey.

I feel ready to go back into the World again. I feel no particular sense of entitlement, though some resentment of the difficulties I have faced. I am better able to face the World.