Another letter .. to my girl who identifies as a boy

An anonymous letter has been published in The Guardian newspaper dealing with the terror parents face of social media sites such as reddit and tumblr ‘telling your little girl she’s really a boy’. You can read this letter here:

Here is another letter, inspired by the anonymous Guardian writer, from a professional thinking critically about the youth transgender narrative who is the parent of a trans identifying teen. 

There was no sign of your transgender identity until you were fifteen when your ‘I want to transition’ announcement came right out of the blue.

When you were little you spent a two-week Christmas holiday in your Disney Princess dress. We had to peel it off you to wash while you were asleep and wriggle you back into it before you were awake. The following Christmas you loved your pink pop-up princess castle so much you took all your presents inside to open and wouldn’t come out. A few years later you chose yourself a rainbow bicycle with pink and silver tassels. You noticed that your brother and the boys next door had different stuff and different clothes and liked wearing your brother’s hand-me-downs and playing his games. He was your absolutely beloved hero. You loved playing football in the garden and hours spent playing knights with wooden swords. But equally you liked to abandon the boys and line up playmobil animals with your best friend Elfie for entire weekends at a time, or bake cakes with her or trampoline or climb trees and teach your doggies tricks. For years both you and Elfie wanted to wear your brother’s hand-me-downs but also you loved outgrown clothes from your girl cousins and older friends. You chose clothes you liked ‘because those shorts are orange’ ‘or ‘that t-shirt has a lion on it’ with no regard for gender.

When you went to the garden party of the Vicar’s ten year old twin daughters in your football strip because you thought fairy dresses were silly I felt in awe of your originality and independent character. You loved sky blue. You said shorts and trainers were comfy. You loved your huge group of girl-friends and being one of them. You never ever said you thought you were a boy.

When you were thirteen you said you were gay. At fourteen you fell in love with a girl who identified as bisexual. You were very concerned about her history of self-harm and took to staying up all night to support her on line, seeking advice from Tumblr, terrified to be away from your phone in case your absence led her to cut herself or stick her fingers down her throat. And then she re-identified as ‘pan-sexual’ (I had to look it up) and hey presto, you re-identified as ‘trans’ and have hardly spoken since.

You briefly told me your friends now call you by a boy’s name and use male pronouns. You found voice lowering training on-line and took to wearing your jeans low slung.  You seemed in a muddle to me because at the same time you wanted me to teach you how to put your long hair in a chignon, paint your toe nails and help you choose a yellow dress for Prom.

I have never minded how you dress or behave in relation to gender. Your Aunty Julie had a boys hair cut as a young teenager, played football until sundown with the neighbourhood boys and was nicknamed ‘Scratch’ because of her fearsome reputation for beating boys in a fight. By seventeen she was training to be a beautician and winning modelling competitions with waist length curly hair that was the talk of the town. Your Aunty Vanessa has never worn a dress in her adult life and I haven’t had any cosmetic routine to inspire you to love applying make-up. I thought the message of your childhood was that everyone, especially you, is naturally beautiful howsoever and exactly as they are.

I haven’t yet directly opposed your plan to become a boy. There were no scenes though I was deeply shocked. We agreed we would both try to find out more about transitioning. I know you’re too young to fully understand your adult sexuality or to definitively know how you want to comply with or challenge the general conventions prescribed for gender conformity in our neighbourhood or your world. You’re not a ‘girly-girl’. That’s what you’ve always said. But until the months of researching self-harm for your girlfriend on Tumblr when you were fifteen, you never, ever said you were not a girl.

And today you wrote to me on whatsapp:

 ‘‘trans people think they’re born in the wrong body and really they’re a boy. I don’t understand that … if someone asked I would still say I was trans though because it’s easier than explaining all that’

And then,

 ‘there’s no point talking about the dangers any more, I know what they are and I’m still going to do it’

Well, I’ve been reading about transgender, the hike in identification of teenage girls as FtoT, listening to the voices of de-transitioners and reading blogs of people who express trans-regret. I have interrogated the evidence on side effects of taking hormones which include – but aren’t limited to – infertility, mental health jeopardy and osteoporosis. I’ve researched the side effects of surgery including physical and psychological scars, urinary tract infections, septicaemia and strokes. I don’t want any of this for you. You have a healthy female body. I cannot stand by and facilitate harm to your body through medical intervention because you are being persuaded it is a requisite for living in the gender of your own choosing. You can live in any gender variation you like. You always have. You always will. But I cannot collude in plans to harm your body. This is not transphobic. It is resisting clinical injury.

I am up against a huge campaign from trans advocates who seek to convince you that medical intervention with all its attendant harms is best for you. I am determined to turn back the tide of those domineering voices. I am not afraid of backlash. I am no longer frozen by your anger or certainty of rejection. I am only afraid that irrevocable harm will come to you if I do not struggle to speak out and turn back the tide of trans tyranny which is blocking sensitive discussion of the divide between gender confusion and intervention. I am your mother. Every fibre of my being is geared towards protecting you from harm.

What if you will not listen and you take steps towards medical intervention even though you know it will not alter your sex or determine your gender or assure you of future happiness? I will still love you. You are my child. However you live in relation to social definitions of gender is fine by me. But I cannot stand passively aside when you are so confused by the transgender trend or cheer you on to the starting line to injure your very own body. Not when you say yourself ‘I don’t understand’.

I have to intervene and to fight for you.

You have all of my love and endless support. You always will.

Mum xxxx

Awakening clinician, UK: What do we think we are talking about?

100 Professional Voices

Another post from a professional reflecting critically on how they see the issue of transitioning children and young people. We aim to publish voices of 100 Youth Trans Critical Professionals to begin to evidence our mutual concern. 

I’m a peripatetic clinician who visits many schools on a regular basis. I’m having my eyes opened by encounters involving gender transitioning children and teenagers.  I have realised there is no room for a liberal woolly professional default position of uncritical acceptance.

Here is a snap shot of things that have happened within the first 4 weeks of going into a number of schools in one borough that have led to awakening concern:

  • A quiet cloak of silence amongst staff, uneasy about who thinks what about ‘Trans Assemblies’ being delivered one day to the school’s Primary Department, separately for the Secondary Dept and separately again for Staff.  Over lunch, a teaching assistant who works in both departments says ‘Oh, I have been to two already, have I got to go to the third?’ There is no reaction or comment from other staff around the dinner table; no questions about what had been learned, opinions, value of the talks attended or why attending Trans Training for a third time seemed a bother. Eyes down and simply no discussion.
  • At an enhanced provision meeting (for children whose needs cannot be met solely from within the school’s resources) I was with a parent, a teaching assistant and a 15 year old young person for whom social communication creates barriers;

Teaching Assistant: ‘He stayed in Assembly this morning. Isn’t that great?’

Mum:  ‘I know. He was worried about it. He’s not very comfortable with that sort of thing even though we’ve always been very open with him’.

Young person: silent

I was unaware until later that the subject was a ‘Trans Assembly’ led by an MtoT individual.

  • Conversation with ‘looked-after’ young person of 13 who tells me: ‘I have two brothers. Well one of my brothers is now a sister’. The teacher said nothing, neither did I. We accept this statement and don’t question what it is like for this young person who seems to have been expected to accept the matter too.  Why not? We probably would have talked further with the child about almost any other disclosure.
  • I watched MtoT individual accompanied by a teacher walking through the corridor of a Primary Resource Base supporting 4-11 year old children who have identified educational challenges. I hoped that opportunities to discuss young people’s identities in relation to a range of issues, not solely transgender, would be given equal weight. I wonder about the privilege afforded to an MtoT person in schools and about equality of representation.

Young people learn much from the adults around them about attitudes, both positive and negative. They need to bounce ideas and be free to hear wide ranging thoughts and opinions, experiences and values. Whilst teaching staff, parents, siblings and peers remain uncertain, with limited information and minimal critical questioning, a worrying veil of ignorance faces young people in their immediate world.

In more or less the same period, just going about my ordinary suburban life, I have heard:

  • My friend’s 15 year old daughter who identified as a lesbian at 13 suddenly re-identifies as FtoT. This is out of the blue – following a period of immersion in Tumblr – social contagion comes worryingly to mind.
  • Another friend’s 16 year old niece attends a single-sex sixth-form where a peer is currently transitioning FtoT. She says they had a day of ‘training’ from a Youth Project in advance of the day of transitioning commencing and were expressly told that to ask any questions would be indicative of transphobia.
  • In the local supermarket a boy of about 7 years old reminds his younger brother … ‘you mustn’t say Uncle Andrew any more because he is a man-lady now’
  •  My sister who is a social worker tells me of concern for a young parent she supports who it is felt may be ‘nudging her 8 year old daughter towards trans’. There is concern that the child’s mother who has mental health issues may be seeking some kind of social-role valorisation for herself through encouraging her child to identify as transgender.

Some of my questions

Why are so many children and young people suddenly identifying or being identified as transgender?

Why are gender and sexuality being confused? Why are we not asking questions about including and valuing everyone in a gender neutral way? Why are many professionals – including myself – suppressing our own questions in public and professional forums?

When we talk about transgender – what do we think we are talking about? 

How do we support people with indeterminate sex (different from indeterminate gender) to feel safe alongside every other individual?

How is medical intervention for children of indeterminate sex a different issue from medical intervening for children articulating gender confusion?

Can we clarify the terminology? ‘Male to Female’ and ‘Female to Male’ seems too binary and incomplete. The issue is ‘Male to Trans’ and ‘Female to Trans’ and using this terminology we begin to encompass a broader, more accurate, notion of the shared experiences and identities of men, women and Trans people.

How do the gender differences that sociolinguistics has identified for years in discourse, including power imbalances, play out with MtoT or FtoT interactions in mixed gender groups? Who gets/is given more air space in conversation at the subtle culturally learned level? What might this mean for collaborative, constructive sharing of views? How might this impact on the experience of transitioning children and young people?  Of particular concern here, is an explanation for why MtoT voices seem to be dominating the campaign for transitioning children and young people. Why does this matter?

What questions do we need to be asking in pursuit of a sensitive divide between gender confusion and social and / or medical intervention?

How can adults and young people work together to understand the new possibilities that medical science offer which impact on social constructs and exist, for a time, in a grey soup of unfamiliarity, devoid of dialogue based on experience?


A Physician’s Perspective: An Overview of Some Problems Associated with Trans Ideology

This post comes from a US physician.

Health professionals behind the “trans youth” ideology advocate a new scientifically baseless standard of care for children with a psychological condition (GD) that would otherwise resolve after puberty for the vast majority of patients concerned.  Specifically, they advise:  affirmation of children’s thoughts which are contrary to physical reality; the chemical castration of these children prior to puberty with GnRH agonists (puberty blockers which cause infertility, stunted growth, low bone density, and an unknown impact upon their brain development at least for the duration they are on the drugs), and, finally, the permanent sterilization of these children prior to age 18 via cross-sex hormones.

There is an obvious self-fulfilling nature to encouraging young GD children to impersonate the opposite sex and then institute pubertal suppression. If a boy who questions whether or not he is a boy (who is meant to grow into a man) is disguised and treated as a girl, then has his natural pubertal progression to manhood suppressed, have we not set in motion an inevitable outcome? All of his same sex peers develop into young men, his opposite sex friends develop into young women, but he remains a pre-pubertal boy disguised as a pre-pubertal girl. He will be left psychosocially isolated and alone. He will be left with the psychological impression that something is wrong. He will be less able to identify with his same sex peers and being male, and thus be more likely to self identify as “non-male” or female.

Moreover, neuroscience reveals that the pre-frontal cortex of the brain which is responsible for judgment and risk assessment is not mature until the mid-twenties. Never has it been more scientifically clear that children and adolescents are incapable of making informed decisions regarding permanent, irreversible and life-altering medical interventions. It is abusive to promote this ideological standard, first and foremost for the harm it visits upon gender dysphoric children, and secondly, for the harm it will cause their non-gender-discordant peers, many of whom will subsequently question their own gender identity, and face violations of their right to bodily privacy and safety once society eliminates sex-segregated spaces as the ideology demands.

When is a support group not a support group? The troubling story of a UK trans support group


This contribution comes from an historian of sexuality and a UK academic.

Just as metaphors lose their metaphoricity as they congeal through time into concepts, so subversive performances always run the risk of becoming deadening clichés through their repetition and, most importantly, through their repetition within commodity culture where “subversion” carries market value.  (Judith Butler, Gender Trouble, 1999 Preface, xxii-xxiii)

My epigraph is from Judith Butler’s 1999 Preface to Gender Trouble, often taken as a foundational text of transactivism. Butler is alert to the way in which liberatory rhetoric can shift into its opposite, turning into a form of oppression. And her warning is appropriate to some of the ways in which transactivism has morphed into a regulatory discourse as it has become established as a business in recent years. The claim of transactivism, of course,  is that it is at the forefront of the fight for a new human freedom. Jay Stewart, energetic founder of the trans youth support group ‘Gendered Intelligence’ [1] draws on Beauvoir, Nietzsche and Butler in his 2014 TED talk ‘We are living on the cusp of a Gender Revolution’ ( His call for the freedom to create an authentic self, for a philosophically nuanced understanding of gender, for a rejection of essentialism, hits the buttons of current academic debate. Who would argue against ‘intelligence’? Who would not support GI’s vision ‘of a world where people are no longer constrained by narrow perceptions and expectations of gender, and where diverse gender expressions are visible and valued.’  ‘Gendered Intelligence’ has worked with the Welcome Institute and the Science Museum. Specializing in art activities for young people from 11 to 25, it provides a supportive space for sometimes troubled youth. Young people who have retreated to the lonely space of the adolescent bedroom can freely interact with others experiencing the same struggles. At last they can find acceptance and belonging. For parents challenged by the changing identities of their young people, the organisation offers both an online forum and a monthly support group where they can share concerns free from worries about ‘political correctness’. What’s not to like?

Well, curiously, quite a lot.  My first visit to the London group was to a parents’ social event in December 2014 where we heard from the actress mother of a trans boy. Engaging and articulate, this mother told how she had wept when her then daughter revealed how viewing a Channel 4 programme ‘The Boy who was Born a Girl’ (Julia Moon, 2009) made her realise that she was a boy. This mother had already suspected that her fourteen year old daughter, attending a private girls’ school with strict uniform codes, was a lesbian (something that came as no surprise to her bisexual mother). But trans was a shock. Coming from a religious background, the mother’s response was to pray and when the next morning she came across a flyer from Gendered Intelligence, she took this a sign. As her teen entered the room to join the other gender questioning young people, she saw that she had come to the right place. Her ugly duckling had become a swan.  And now, two years later, despite the slowness of the NHS, her daughter was at last about to start hormones. At this point the room broke into spontaneous applause.

The applause worried me.  For the mother’s story raises a number of questions. Should a TV programme be the basis for irreversible medical intervention? Might not a teenager be made to feel uncomfortable about an emerging lesbian identity within the context of a private London single sex school?  Was the chance discovery of a leaflet for Gendered Intelligence really a sign from God? And how free was the child to pass through what might have been a transient phase once enrolled in a group where her newly formed identity would be reinforced by adults?

In the world of ‘Gendered Intelligence’, the thought ‘Am I the other sex?’ is not a thought that can be challenged but is taken as a revelation of an essential truth. The role of the adult and of the parent is to support and affirm this identity. At the monthly parents’ group, we were encouraged to speak freely and not to feel that we had to be ‘politically correct’. But there was an underlying narrative: feelings were our own but the facts were in the possession of the convenor, and those facts were the ‘trans narrative’.  Our children could only be happy if we supported them through transition. We would find it difficult, we might grieve for the child we might feel we had lost but this was merely part of a journey familiar to our experienced convenor, herself the parent of a trans man (who transitioned from female to male I think at age 21). The presence of this convenor necessarily makes it hard to question the trans narrative. ‘Where are you on the journey?’ asked the parent convenor, when I introduced myself.  My answer, ‘Which journey?’ did not go down well.

As Butler suggests, a narrative designed to liberate can itself become oppressive when it turns into doctrine. Some parents revealed that they feared their kids were subject to peer pressure. A visibly unhappy couple were still in shock after their daughter’s announcement that she was trans. She was in her final year at university and they feared that the announcement reflected the undue influence of a new partner with strong links to trans activism. They were particularly worried that this partner had separated their daughter from her other friends. Another mother said that her ‘trans’ daughter was was voicing just the same kind of worries about her appearance that she herself had experienced at the same age. The difference was that her daughter was being encouraged to transition by her friends.

The stories were often troubling, suggesting in some cases that it was the parents who were taking the lead in pressing for their children to transition. Perhaps it is hard to understand why this should be so.  It may be that certainty (supported by the GI community) is easier than doubt. It may also be that gender dysphoria (unlike mental illness) is a diagnosis currently free from stigma which (understood as innate) allows parents to escape guilt. A couple were paying privately for female hormones for their son at Gender Care (a private gender clinic) because the NHS process was too slow. They were also paying for the injections to be provided by a private nurse because there was no agreement of care with the GP. During his first year at university, their son had stayed in his room, worked very hard and got a first. He had decided at this stage that he was trans and had bought hormones on the internet which had worked very quickly. He was now taking a year out of university so that he could begin again as a woman. But he had also developed agoraphobia and was terrified to go out in case anyone should detect that he was trans. At the same time he drew attention to himself by wearing bright red lipstick. These parents, perhaps terrified of suicide, said that if their was happy for a month it was worth it. Yet the changes they were paying for have irreversible life long results.

No mention was made to the parents’ group of the statistical likelihood that gender dysphoria in a child or adolescent would spontaneously disappear as they matured. None of the parents described their children as having displayed gender nonconformity as young children. Instead it had developed suddenly around a critical stage in their education when they were likely to be under stress, whether GCSEs, A levels or at university. When I pointed out that a majority of those who enrolled at the Charing Cross GIC dropped out and so did not proceed with medical transition my claim (derived from the information pack for new patients) was challenged by the convenor who explained that trans people might be put off by the questions they had to face at the GIC. For this reason, some might simply live as trans without medical help. But we were told that things were getting better all the time, and that there were people who had been trans all their lives and were able now to transition medically in old age.

Unchallenged both online and in the group was the belief that transition necessarily requires surgery – a belief that the NHS and all responsible advice on gender dysphoria rejects. The convenor was proud that she had been able to accompany a young transwoman to the gender identity clinic and to support her through surgery.  Posters on the GI parents’ online forum are preoccupied with accessing medical intervention including surgery as quickly as possible. One thread discusses how to obtain a mastectomy (‘top surgery’) for a child under 18, something that is not available on the NHS.  Private Brighton surgeon Andrew Yelland ( is recommended as ‘the only surgeon I found who would do chest surgery for over 17’.  The problem, though, is that ‘Mr Yelland requires a referral from an ADULT psychiatrist to do the surgery on an under 18 year old’, something that is not offered on the NHS. Parents recommend contacting ‘Stuart Lorrimer (enqu… and it cost £200. We sent a Tavistock referral letter to both Stuart Lorrimer and Mr Yelland so they both had the basic info.’  Let’s pause to make this clear: for a fee of £200, it is claimed, Stuart Lorrimer (a psychiatrist employed at the NHS Gender Identity Clinic at Charing Cross), will write a referral authorizing  a mastectomy for a seventeen year old patient at the Tavistock whom  he does not treat himself and whom his private clinic (Gender Care) is not licensed to treat.


But these are the tricks a supportive parent can pick up from the Gendered Intelligence online parents’ forum. Though, as Butler warns, ‘“subversion” carries market value’. In this case, ‘The surgery with Mr Yelland costs £6K and he operates on a Monday and Wednesday.’ [2]

Though revealing – and worrying – the GI online forum could be dismissed as peer support whose content in no way reflects the ethos of the organisation that enables it to function. Yet the parents’ group revealed equally worrying stories where a host of co-morbidities were ignored in order to privilege the issue of gender.

A central feature of of the trans narrative is the claim that trans is not a mental illness. There is a curious asymmetry in the ways in which gender dysphoria (the belief that your body does not match your gendered identity) and body dysmorphia (the belief that your body is aesthetically unpleasing) are understood.  According to NHS Choices, ‘up to one in every 100 people in the UK may have BDD [body dysmorphia disorder]’, a condition that ‘usually starts when a person is a teenager or a young adult’.[3]  Body dysmorphia disorder is treated with CBT and anti-depressants because surgery ‘can lead to a preoccupation with further surgery to try to get a better result, which in some cases will do more harm to a person’s appearance than good.’  Sensible. But then ‘BDD is a psychological or psychiatric problem and thus needs psychological or psychiatric treatment.’[4]  By contrast, NHS guidance states that dissatisfaction with the body stemming from beliefs about gender identity ‘is not a mental illness’.[5] In this case, a physical treatment is therefore appropriate: ‘Many trans people have treatment to change their body permanently, so that they are more consistent with their gender identity, and the vast majority are satisfied with the eventual results.’ Let’s not worry for a moment that there is a dearth of long term follow up evidence for a treatment protocol described as ‘a unique intervention not only in psychiatry but in all of medicine.’ [6] For what there is, shows only that ‘Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.’ [7]

According to the parents, the children who attend Gendered Intelligence have serious co-existing problems.  Yet in the parents’ online group, transition is offered as a panacea for all problems. Here’s a mother, discussing her 17-year-old MTF child’s depression: ‘incommunicado, never leaving her room. She also has chronic pain syndrome in her leg which may excuse some of this behaviour as she is in extreme physical pain frequently, doesn’t sleep much/well, due to the pain and is taking strong painkillers. However she doesn’t do the recommended stuff to overcome the chronic pain so I suspect it’s all much more down to the gender dysphoria.’ Guidelines for GPs warn against ‘misattributing commonplace health problems to gender’.[8] The mother intuitively gets this key point: ‘Sounds like she has severe depression actually’. But the belief (unchallenged within GI) that transition is curative prevents children from accessing appropriate mental health services. ‘With luck, she’ll attend the 1st GIC appointment and things may begin to look up’, says the mother.[9]

A similar picture emerged at the monthly parents’ group. A mother who attended alone was clearly upset and did not speak until near the end. Although she accepted her sixteen-year-old daughter’s transition she was worried because she was self harming and would not attend school. That day her daughter was depressed and in bed because her period had started. Yet the child’s belief that her problems stemmed from gender dysphoria meant that she was refusing to engage with CAMHS (the child and adolescent mental health team). The daughter would only attend the Tavistock in order to get hormone blockers and later testosterone but hated the therapists.

It is known that a significant proportion of trans kids are autistic.[10] Yet the role of autism in the understanding of social gender stereotypes is not discussed nor is a diagnosis of autism a contraindication in accessing medical transition on the NHS. One couple told how their tall son (on the autistic spectrum and doing A levels at an all boys’ school) had announced that he was trans. His interests were stereotypically masculine (trains etc). He had low self esteem and was physically unconfident. He would hold his hands in front of his chest as if to hide his body. His parents were always telling him to stand tall and open his chest and the mother seemed to feel disappointed with him. One day the mother was going through his clothes to see which still fitted him and which should be given away. She commented that he had put on weight and was beginning to develop breasts. (Humiliated?) he said that it didn’t matter because he was really a girl. The mother readily accepted the news and told him that he should go to the GP. The boy said that it was embarrassing and that he did not want to go. But the mother forced him to attend. She said that she was having to make him grow up and take responsibility for his medical treatment. He would have to deal with forms as soon as they arrived or he would not keep up with the process of transitioning. Although the father was struggling with the change both parents had enrolled themselves at the Tavistock and were trying to speed up their son’s transition even though he had not insisted on a female pronoun and had not begun to think about changing his name. At no point did it seem to occur to the meeting that this child was being rushed into transition by parents who had become stalwarts of the Gendered Intelligence parents group.

Far from offering ‘a world where people are no longer constrained by narrow perceptions and expectations of gender, and where diverse gender expressions are visible and valued’, ‘Gendered Intelligence’ resembles a cult in which medication and surgery are rites of passage and belonging. Despite a veneer of openness and despite idealistic motivations, it is a place where adults coerce the young towards a predetermined destination. In Philip Pullman’s 1995 trilogy for young adults, His Dark Materials, charismatic adults attempt to persuade children to undergo ‘intercision’, a ‘tiny cut’ that is variously compared to (but is not the same as) the creation of castrati by the Catholic church and female genital mutilation: ‘‘the doctors do it for the children’s own good, my love…[A] quick operation on children means they’re safe….All that happens is a little cut, and then everything’s peaceful. Forever!’’  [11] The promise by trans support groups that medication and surgery will provide peace from the difficult feelings that assail the young is equally dangerous.









[2] All quotations from the parents’ online forum have been anonymised. I have not included screenshots in order to respect the privacy of posters.
[6] Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
[7] Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Långström N, Landén M (2011) Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885. doi:10.1371/journal.pone.0016885
[9] Post from 22/6/2015. Anonymised to respect privacy.
[11] Philip Pullman, Northern Lights, 284

A Psychoanalytic Perspective

I am grateful to Robert Withers for giving me permission to quote at length from his article which appeared in the June, 2015 issue of the Journal of Analytical Psychology. In this piece, Withers relates the cases of two transsexual patients, and considers how fears of pathologizing such patients can lead the analyst to overlook or avoid important elements. Withers also addresses diagnostic issues related to transsexuality. I will begin this post with a lengthy quote about Wither’s work with his patient Chris.

Chris had had male-to-female SRS, but wished to return to living as a man. As I struggled to process my shock at his story, my initial thought was that the best therapeutic outcome might well be for him to learn to accept himself as a woman. When his penis had been removed in the original operation, some of the foreskin and its associated nerve tissue had been fashioned into a kind of clitoris, and his scrotum into an artificial vagina. Unfortunately, there had been complications. He had suffered repeated urinary tract infections. The work of the original operation had broken down and the artificial vagina had had to be reconstructed using a piece of his gut. The clitoris did not seem to really work and he was unable to experience proper orgasms. Surgery could restore him a prosthetic penis, which however would never give him real sexual pleasure. A date had been fixed for an operation to have his breast tissue removed, and he had stopped taking the oestrogen routinely prescribed for male-to-female transsexuals.

 Inwardly recoiling from all this surgery, I asked him why he wanted to revert to living as a man. He replied that he had come to realise that the original operation had not solved the problems he had hoped it would. A couple of years earlier, after living as a woman for nine years, a significant moment had occurred. He had introduced himself to a new psychiatrist who had told him ‘But you are not a woman are you? You are a man who has had mutilating surgery’. I gasped involuntarily at what I regarded as this psychiatrist’s monumental insensitivity. But Chris held my gaze steadily and replied matter-of-factly that he had been right.

 I began to be filled with a deep sense of admiration for this man who was so determined to face up to his mistakes, and from whom I learned so much. I started to feel rather ashamed of my earlier impulse to encourage him to cut his losses and live as a woman. Chris himself was full of rage with an ‘industry’ that he felt had sold him the illusion that having SRS would solve his psychological problems, ‘It is as daft as if I were to go to a psychiatrist with the delusion that I was a kangaroo and he had said, “fine, if you can live in role as a kangaroo for a couple of years and come to a few counselling sessions over that period of time, then provided you still believe you are a kangaroo, I will refer you for an operation to have a pouch fitted”’. I could see his point. But why, I wondered, had his counsellor and psychiatrist so spectacularly failed to address the obvious psychological issues behind his wish for SRS prior to surgery, even if the number of sessions they could offer was perforce minimal?

 Chris replied that it was not their fault. Even in those days, before the advent of the internet, nearly everyone wanting the sex change operation was familiar with all the relevant literature and knew exactly what the psychiatrists and counsellors ‘wanted’ to hear. A ‘helpful’ transsexual community had schooled him in what to say in these interviews. And he had thoroughly read and digested the works of Robert Stoller. All he had to do now was to show strong motivation and demonstrate the clear conviction that he had thought of himself as a girl from an early age, while avoiding divulging any information that might lead to an alternative ‘diagnosis’ such as homosexuality, transvestism or a ‘paraphilia’; he carried this off with aplomb. Of course, some of these diagnostic criteria have since changed. He would no longer have to hide such things as his wish to live in a sexual relationship with a woman, for instance.

 Withers’ work with Chris informed his subsequent work with a second transsexual patient who was seeking SRS, but had great difficulty tolerating any exploration of serious issues from his childhood. In the course of musing on his brief and ineffective attempt to engage the second patient in an exploratory process, Withers makes several important points.

There are currently no good diagnostic guidelines that indicate who will benefit from SRS and who will be harmed by it. This fact alone should make us very hesitant to support medical intervention with children identified as trans. Children who are prescribed puberty blockers followed by cross sex hormones will be permanently sterilized, and their natal genitalia will not have developed, likely making surgery much more desirable, if not necessary.

Trans activists lead us to believe that transition is the only and best treatment for gender dysphoria, and that preventing transition can lead to suicide. However, there is no evidence that this is the case. Below is another quote from Withers’ article.

Several studies (Moskowitz 2010,, etc.) suggest that over forty percent of transsexuals either attempt suicide or succeed in killing themselves post surgically. Some in the ‘trans’ community (e.g. ascribe this to society’s intolerance. But one would expect this to be reduced after surgery as it became easier to pass as one’s chosen gender. And yet the suicide rate for post-operative transsexuals is around twenty times higher than for a control group matched in terms of age, social position and psychological morbidity (Dhejne et al. 2011). It is not clear whether this is because of dissatisfaction with the operation or because transsexuals as a group are already prone to suicide attempts and self-mutilation pre-surgically. Either way, this should ring alarm bells, rather than reinforce confidence in either Stoller’s diagnostic categories or the benefits of surgery.

 Give that there is no degree of certainty that transition reduces the risk of suicidality, the ethics of permanently sterilizing minors seems questionable at best.

Withers also addresses the conundrum of transsexualism’s etiological origin. Trans activists want the condition to be “real” – that is, not psychological. This motivates some to look for a physical cause since, as Withers points out, there is a “cultural prejudice that confuses the physical with the real.” Efforts have been made to assert that the cause of transsexualism is physical, usually by suggesting that it is in the brain. However, the evidence for a physical basis for gender identity in the brain is weak. One of the studies most often cited had a sample size of nine.

Moreover, even if we were to accept that there is a physical basis for gender identity in the brain, that would tell us nothing about how we ought to respond to the condition. For example, there are well established brain differences and genetic factors in such conditions as dyslexia and anorexia. In neither case does the fact that there is a physical basis for the condition mean that the condition is not treated as potentially harmful or functionally compromising. It is my hope that we do not punish or stigmatize anorexics or dyslexics. Nor do we deny the reality of what they suffer. We do offer them support and treatment so that they can best manage the aspects of their condition that make it difficult for them to function and live a healthy, happy life. With or without a physical basis for gender identity, we as a society should be committed to providing the same kind of support to transsexuals. It doesn’t necessarily follow, however, that medical transition is the best and only support needed.

Etiology of transsexualism gets to the heart of one of the many contradictions that arise when one begins to examine the assumptions of the trans community. Withers summarizes the Lacanian view that transsexualism is symptomatic of psychosis. With this assumption, of course medical transition is not indicated, as it would be colluding with the psychosis. Trans activists have sought to depathologize the condition in much that same way that being gay or lesbian has thankfully been depathologized. But if being trans is a normal variant of human sexuality, then why does one need to change the body with hormones and surgery?

“Without a notion of the unconscious, it seems natural to assume that psychopathology must either be imaginary or chosen, and therefore the individual’s fault,” writes Withers. He goes on to explore several examples in which trauma almost certainly played a role in the etiology of gender dysphoria in several cases examined in the article. If transgender identity is sometimes affected by unconscious dynamics – as it is likely to be most of the time – then responding to this distress with a physical fix does transgender individuals a disservice. In so doing, clinicians may be colluding with a patient’s defenses by encouraging them to think of their problems as primarily physical.

The suffering of people such as Withers’ patient Chris shows us that these are not merely academic arguments. Especially as more and more children receive hormonal treatment for gender dysphoria that sometimes results in permanent sterility, the stakes are quite high.

Though many who have had SRS report that they are happy having received the surgery, Withers cautions us to consider these claims with a pinch of salt.

As my ex-patient Chris said, ‘How many males having had their body and genitals radically altered by hormones and surgery will tell their story? Better to say nothing or cover everything up with self-justification, half-truths and rationalization.’ But even if Chris were wrong and these claims are right, it seems hard to justify a surgical procedure with no reliable means of telling in advance who is likely to benefit from it. Analysts might argue that this is not their concern and that the responsibility for recommending surgery lies elsewhere. In practice, this is true. But, if we can agree that SRS is being used defensively–if it is being sought (for instance) in the unconscious hope of avoiding the pain of abandonment by mother and identification with a violent, abusive father–then, surely, it is the psychoanalyst’s (rather than the surgeon’s, psychiatrist’s or doctor’s) responsibility to attempt to work through these issues with the patient?

Withers ends his article with a final poignant quote from Chris. I shall end this blog post the same way.

Looking back I rather wish the diagnosis of transsexual had never been coined. I think is has robbed many individuals of their unique and talented humanity, handing it over to the waiting rooms and operating theaters of a psycho-sexual empire whose role now seems, to me, to place the individual confused with their “gender identity” into a third stereotype little better than the two we were once tethered to.

 Withers, R (2015), The seventh penis: towards effective psychoanalytic work with pre-surgical transsexuals. J Anal Psychol, 60, 390–412. doi: 10.1111/1468-5922.12157.