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.