Summary

Lisa Marchiano describes her therapy with 'Maya', who identified as trans as a teenager, was quickly affirmed by a school psychologist, and was prescribed testosterone at 18 after a short clinic visit with no real assessment. Her mental health got worse on testosterone, with two psychiatric hospital stays. She stopped hormones and identified as female again before starting therapy. Using Jungian ideas, Marchiano links Maya's gender distress to grief she never worked through for the aunt who raised her, a hard relationship with her mother, and a wish to escape being a woman. She argues that affirming care can turn emotional pain into a problem with the body. The case shows that gender distress can carry other meanings for some people. But it is one case, pieced together afterwards by a critic of affirming care, and can't be generalised.

Key findings

• The paper is a report on one patient in in-depth talking therapy: 'Maya', a young woman who took testosterone for almost two years and then identified as female again.
• Maya began identifying as trans at 14 after spending more and more time online. A school psychologist quickly affirmed her identity and urged her parents to support medical transition.
• At 18, without her parents involved, she was prescribed testosterone at a clinic that asks only for informed consent, after a 30-minute meeting with a physician assistant.
• On testosterone her mental health got worse, with two psychiatric hospital stays, one because she intended suicide. She stopped hormones partly because she suspected they were making her mood worse.
• Her history included losing the aunt who cared for her when she was young, emotionally distant parents, bulimia and ADHD (attention deficit hyperactivity disorder). The therapist sees her trans identity as partly a way of avoiding grief and a difficult bond with her mother.
• The author argues that affirming care can turn emotional distress into a problem with the body and shut down exploration. She favours in-depth therapy before medical steps.

Abstract

Within the last decade, there has been a sharp global rise in the number of young people identifying as transgender. More recently, there appears to be an increase in the numbers of young people detransitioning or returning to identifying with their natal sex after pursuing medical transition. A case is presented of a young woman who pursued a gender transition and returned to identifying as female after almost two years on testosterone. The author considers and critiques the affirmative model of care for gender dysphoric youth in light of this case.

Conclusion

The case of Maya illustrates the extent to which her presenting problem was a metaphor for unresolved grief and deficient parenting which was later exacerbated by both peer and professional wounding. The purpose of psychological treatment is to bring unconscious issues to consciousness, thereby recovering and reconnecting affect, cognition and reality. Depth psychology posits the active presence of unconscious compensation and symbolization processes. We owe it to young people to explore multiple facets of any individual's expressed desire to transition. For some people, living life in the opposite sex role - even to the point of undergoing physical transition - may be what the psyche requires of them. We help our patients best by affirming the significance of their experience but without explicitly endorsing a specific course of action.