Summary

Psychoanalyst Roberto D'Angelo argues that it has become hard to ask why a young person wants to medically transition. He says the questions are blocked in three places: by the young person's own defences, in the therapy room, and by a political climate that calls such questions conversion therapy. His example is 'Elly', a trans-identified teen whose fixed story gave way, over long therapy, to memories of abuse by her mother. She still started oestrogen at 18. He points to UK, Swedish, Finnish and German evidence reviews that found the benefits of youth gender medicine uncertain. He argues careful exploration is an ethical duty before treatment that cannot be undone. He also sharply criticises fellow analysts who call this work transphobic. It is an opinion piece built on one case, by the president of SEGM (a group that urges caution), and has drawn published critiques.

Key findings

• Dans le cas d'Elly, une histoire de maltraitance et de négligence par sa mère n'est apparue qu'après 18 mois de thérapie.
• L'auteur soutient que sa détresse de genre était enchevêtrée avec une douleur non élaborée qu'une courte évaluation en clinique n'aurait jamais découverte.
• Il cite des revues des preuves du Royaume-Uni (la Cass Review), de Suède, de Finlande et d'Allemagne qui ont jugé très faibles les preuves sur les bloqueurs de puberté et les hormones du sexe opposé chez les jeunes.
• Il dit que de graves préjudices physiques, dont des risques cardiaques et vasculaires et l'infertilité, sont bien établis.
• Il décrit une « interdiction de savoir » à tous les niveaux : les patients résistent à explorer leurs sentiments sur le genre, et un climat politique traite toute remise en question de transphobe ou de thérapie de conversion.
• Il soutient que des analystes réputés favorables à la transition médicale déforment la position des thérapeutes qui demandent « pourquoi » et négligent la souffrance des détransitionneurs.
• Il suggère que sa profession surcorrige peut-être par culpabilité d'avoir jadis traité l'homosexualité comme une maladie, et que les thérapeutes évitent peut-être l'inconfort d'accompagner un jeune qui demande des changements corporels permanents.

Abstract

The weak evidence base and profound consequences of gender-affirming interventions for youth call for a particularly sensitive and complex psychoanalytic exploration. However, prohibitions on knowing at the individual and social levels significantly constrain psychoanalytic work with trans-identified youth. Barriers to exploration and thinking that patients bring to treatment are reinforced and reified by the dominant socio-political trends that saturate the contexts in which young people dwell. These trends increasingly frame any attempt to deeply explore why a young person is seeking medical or surgical gender-affirming interventions as “off-limits” and a form of conversion therapy. Furthermore, politically driven clinicians who promote medical gender-affirming interventions misrepresent and attempt to discredit clinicians who explore the meaning and function of trans identification, or who express concern that transitioning may be a drastic solution to various forms of psychic pain. In doing so, they minimise the significance of the weak evidence base for these interventions and their serious, known risks. At the same time, they obscure or deny the psychic pain that is sometimes humming beneath the experience of gender dysphoria. The author asks: If there are significant uncertainties and risks of harm associated with medical interventions for young people, do we want to know?

Conclusion

D'Angelo concludes that psychoanalysis has an ethical duty to resist these prohibitions. The analytic process—slow, uncertain, and often uncomfortable—is precisely what can help young people determine whether transition will help them thrive or whether their gender dysphoria is a carrier for other, unaddressed pain. He asks the profession directly: if there are serious uncertainties and risks of harm, do we want to know?