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

• I fallet Elly kom en historia av övergrepp och försummelse från hennes mor fram först efter 18 månaders terapi.
• Författaren hävdar att hennes könsrelaterade lidande var sammanflätat med obearbetad smärta som en kort klinikbedömning aldrig skulle ha funnit.
• Han hänvisar till evidensgranskningar från Storbritannien (Cass-rapporten), Sverige, Finland och Tyskland som bedömde evidensen för pubertetsblockerare och korskönshormoner hos unga som mycket svag.
• Han säger att allvarliga fysiska skador, inklusive hjärt- och kärlrisker och infertilitet, är väl belagda.
• Han beskriver ett ‘förbud mot att veta’ på alla nivåer: patienter motsätter sig att utforska sina känslor kring kön, och ett politiskt klimat behandlar varje ifrågasättande som transfobiskt eller som konverteringsterapi.
• Han hävdar att välkända analytiker som stöder medicinsk transition missframställer terapeuter som frågar ‘varför’ och förbiser detransitionerares lidande.
• Han antyder att hans yrkesgrupp kanske överkompenserar av skuld för att man en gång behandlade homosexualitet som en sjukdom, och att terapeuter kan undvika obehaget i att sitta kvar med en ung person som söker permanenta kroppsförändringar.

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?