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, http://www.lauras-playground.com, 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. http://www.lauras-playground.com) 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.

13 thoughts on “A Psychoanalytic Perspective

  1. Thanks for a clearly expressed and well-thought out article. When so much is at stake, it’s as well to look critically at outcomes for clients. We seem to have jettisoned evidence-based practice in favour of ideology.


  2. I changed your paragraph around for you so it will make better sense to everyone.

    Moreover, even if we were to accept that there is a physical basis for homosexuality 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 homosexuality, we as a society should be committed to providing the same kind of support to gay people. It doesn’t necessarily follow, however, that gay marriage and allowing them to be foster parents is the best and only support needed.

    How do you like those changes? Do you support them?


    1. I actually don’t like those changes, and I don’t support them. I am firmly and strongly in favor of same sex marriage, and same sex couples becoming parents in whatever way they choose.

      The authors of this site — I will say it again and again — are interested in raising awareness and critical thinking around medical intervention for trans identified youth because we are concerned that medical intervention brings permanent, serious changes, and that young people are making these decisions before they have the maturity to reckon the effects.

      Liked by 2 people

    2. Homosexuality is not comparable to transgenderism as transgenderism is a western medical intervention that utilizes artificial hormones and surgery in an attempt to make people look like the opposite sex.

      Liked by 3 people

  3. I need help and I don’t know what to do.

    Here is my story.

    My 17 year old daughter has decided that she is a man since last year and she is going towards the path of having hormone therapy and surgery.

    My daughter had shown no signs of masculinity in her childhood at all and in fact she avoid toys meant for boys and she never participated in any masculine activity that I know of. As she grew older she was buying very feminine clothes and would not ever select to shorten her hair even by an inch. She started shaving her legs and even arms, plucking her eyebrows at a very young age to my dismay however I did not stop her. Despite being very pretty and even thin, she would always would believe that she is fat as she grew older she experienced the typical teenage eating disorders.

    Her personality at home would be of very caring towards us, her pets and friends and usually cheerful when she was younger and we trusted her. However she had learning issues and was she being bullied by the kids and teachers and even us the patents quite often because of her performance as the school would often complain and that was a major cause of stress at home and there was always battle of homework.

    Her competency in learning has vastly improved throughout the years however she has consistently needed our help to pass most of the technically challenging courses and while it is her that is selecting them and yet not working on them and this has continued to cause massive stress in our family although we have been willing to help while she would be goofing off.

    The flip seems to have happened last summer of last year after she failed a course and had to repeat it. She claims she has felt that for few years although neither I nor my husband noticed a thing although I would notice that I could not separate her from internet. My husband would always supply her with access because she is the only child and in need of communication despite my disagreement. The sudden transition has been about vast changes in her personality and even in her gate while walking, displays of aggression, yelling and insulting language towards me mostly and less often towards my husband.

    I sometimes think that she may have a brain tumor. She has changed her name at school and she has been going to boys washroom without our knowledge for half of last year.

    As parents neither I nor husband have any bias against homosexuality. However I don’t believe that transsexualism makes any sense as it relates to her given her history and my husband believes the same thing but he is going along with her wishes to take her to clinic to have her transition. So basically I have no support to voice my opinion and they talk over any objections that I have.

    She is getting few personal therapy sessions for her poor behavior and nothing positive has resulted from that that I can report.

    I must add that she wants to have kids and yet have her womb removed and save her eggs have someone else to produce her baby when she gets older!! She is 5’2” and so she not have a manly stature either. I am afraid that she will end up eunuch, lost and lonely with more issues than she already has. She has no other family other than us to help her and both of us are getting old.

    I believe that her problems are psychological in nature and related to lack of feeling success and needing negative attention and such transition would equate to unnecessary elective mutilation that would fail to help her although she believes that they will.

    My husband refuses to read anything on negative outcomes and he believes that I am cherry picking the medical literature when noting the probability of poor of outcome and so I have no influence on him or her to change their minds.

    I have not been able to eat or sleep properly for months.

    I need some kind of helpful advice to stop her before irreversible damage is done to her.

    Liked by 1 person

    1. There are many mothers who agree with your thoughts. Have you seen 4thwavenow? I think you will get a lot of information and support there. Don’t worry, you are not alone!

      Liked by 1 person

  4. (((A MOM)))

    I am not a psychiatric professional and I’m hoping that the extremely intelligent and caring individuals on this site, who are, will also provide input to you in your situation. My heart really goes out to you!

    Although our lesbian daughter appears, for the moment at least, to be desisting from active efforts towards transition, I have also had the very serious problem of disagreement with my spouse about how to deal with a problematic child. In our case, our oldest son (from an early age) displayed troubling signs of dishonesty and amorality and we could never agree on how to effectively deal with what I thought were flashing red alarm signs, and my husband thought were just normal developmental glitches. As his teenage and young adult years wore on, he developed a boatload of problems, some related to straight-up medical issues, but this was greatly exacerbated by his addiction and mental health problems. At age 26, he is currently in what appears to be an unstoppable spiral of drug and alcohol use, homelessness, repeated arrests/incarceration, multiple suicide attempts and involuntary hospitalization.

    To put it mildly, this has almost destroyed our marriage. For years on end, we would sit and look at each other and ask, what should we do? We disagreed at almost every turn about what would be the most effective approach. We fought endlessly about how to deal with him, and he, in turn, exploited the differences between us, in order to slither between the cracks and do what he wanted to do. Kids are smart. They will figure out any strategy, including actively encouraging conflict between the parents, to get what they think they want.

    Finally, after 10 years of complete dysfunction, and 3 years of intense chaos, we are on the same page. My husband has finally accepted that there is really nothing we can do to help our son, and that everything we have tried, has actually backfired. We are trying to repair our relationship and it is taking a lot of work. I wish that the two of us would have sought counseling earlier to try and address some of the damage this caused – nobody ever enters a marriage, thinking they’ll have to deal with something like this.

    This is NOT at all to say, you and your husband should come to the same place regarding your daughter as we did, regarding our son. It is concerning to me, however, that as her mother you seem to have no say “at all” in what happens to your daughter. This isn’t how a healthy marriage works (I know you know that). I wonder if you could try talking to your husband and asking, why he is in such a rush to see his daughter become his son. Is he uncomfortable with the idea that she may be lesbian and would actually rather have a straight son? Or do you think he has been “buffaloed” by the claims of trans-activists that your daughter will commit suicide if she can’t get what she thinks she wants? Is he familiar at all with the fact that at least 80% of “GNC” children ultimately desist from attempting to become the opposite sex? Is there any way he might consent to at least a slow-down in the rush to trans for your daughter? Just in case? I assume she’s already gone through puberty, or at least mostly so, so it isn’t like she “has to” suppress her sexual development at this point.

    I don’t know, I just see that you are in a very tough place here and I wish you all the best.


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