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

• エリーの症例では、母親による虐待とネグレクトの経緯は、18か月のセラピーの後でようやく明らかになりました。
• 著者は、彼女の性別への苦痛が、短いクリニックの評価では決して見つからなかったであろう、処理されていない痛みと絡み合っていたと主張しています。
• 若者への思春期ブロッカーと異性ホルモンのエビデンスをきわめて弱いと評価した、英国（キャス・レビュー）、スウェーデン、フィンランド、ドイツのエビデンスレビューを引用しています。
• 心臓と血管のリスクや不妊を含む、深刻な身体的害は十分に確立されていると述べています。
• あらゆるレベルでの「知ることの禁止」を述べています。患者は性別についての自分の気持ちを探ることに抵抗し、政治的な風潮はあらゆる疑問をトランスフォビア、または転向療法とみなします。
• 医学的トランジションを支持する著名な分析家は、「なぜ」と尋ねるセラピストを誤って伝え、デトランジショナーの苦しみを見落としていると主張しています。
• 彼の専門職は、かつて同性愛を病気として扱ったことへの罪悪感から過剰に是正しているのかもしれず、セラピストは、永久的な身体の変化を求める若者のそばに留まる居心地の悪さを避けているのかもしれないと示唆しています。

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?