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

• 在艾莉的案例中，母親虐待與忽視她的歷史，直到治療 18 個月後才浮現。
• 作者主張，她的性別困擾與未被處理的痛苦糾纏在一起，而簡短的門診評估永遠不會發現這點。
• 他引用英國（Cass 檢討報告）、瑞典、芬蘭和德國的證據審查，這些審查將青少年使用青春期阻斷劑和跨性別荷爾蒙的證據評為非常薄弱。
• 他說嚴重的身體傷害，包括心臟與血管風險和不孕，是已被確立的。
• 他描述了各個層面都存在的「禁止知道」：患者抗拒探索自己對性別的感受，而政治氛圍則把任何質疑都當成恐跨或扭轉治療。
• 他主張，著名的支持醫療過渡的分析師歪曲了詢問「為什麼」的治療師，並忽視了去過渡者的痛苦。
• 他認為他的專業可能因為對過去把同性戀視為疾病而感到內疚，因此矯枉過正，而且治療師可能為了避免面對尋求永久改變身體的年輕人時的不適。

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?