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

• 在Elly的案例中，母亲虐待和忽视她的经历直到治疗18个月后才浮现出来。
• 作者认为，她的性别痛苦与未被处理的痛苦纠缠在一起，而短时间的诊所评估永远不会发现这一点。
• 他引用了英国（Cass评估）、瑞典、芬兰和德国的证据评估，这些评估将年轻人使用青春期阻断剂和跨性别激素的证据评为非常薄弱。
• 他说，严重的身体伤害，包括心脏和血管风险以及不孕，已被充分证实。
• 他描述了各个层面上存在的“禁止知晓”：患者抗拒探索自己对性别的感受，而政治氛围则把任何质疑都视为恐跨或转化治疗。
• 他认为，支持医学过渡的知名分析师歪曲了询问“为什么”的治疗师，并忽视了去过渡者的痛苦。
• 他认为，他的行业可能是出于对曾将同性恋视为疾病的内疚而矫枉过正，治疗师可能在回避面对一个寻求永久性身体改变的年轻人时的不适。

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?