Exploring Gender Dysphoria: A Psychotherapeutic Perspective on Internal and External Influences, particularly looking at the developmental issues associated with some young trans men.

Gender dysphoria refers to the discomfort or distress experienced by individuals due to a mismatch between their biological sex and gender identity. This article provides a psychotherapeutic perspective on the internal and external factors contributing to this condition. Understanding the root of psychological distress and its manifestations is complex and multidimensional. While social forces play a significant role, this exploration primarily focuses on the internal narratives shaped by early experiences. It is important to acknowledge that internal factors significantly influence perception, and a combination of nature and nurture influences an individual's development and worldview. The thoughts presented here are not intended to constitute a comprehensive theory applicable to all children experiencing gender confusion but rather an exploration of general phenomena. Many young people with gender dysphoria express a strong sense of knowing their true gender from an early age and feel the need to undergo a medical transition to live authentically. They often hold firm beliefs and may express doubts about their decision to their parents or relatives. However, it is crucial to consider the potential risks and long-term consequences of medical transition, including irreversible physical changes and the need for lifelong medical care. Challenges for psychotherapy Firstly, the young person may resist any questions or doubts raised by others, believing they have found the solution to their suffering. Secondly, instead of addressing distressing psychological symptoms such as feelings of detachment from their birth body, the patient may view their issue as being born into the wrong body, seeking a physical solution to a psychological problem. 

In contrast, the therapist's role is crucial in exploring the unconscious forces behind the patient's belief system. The goal is to cultivate the individual's interest in self-reflection through a curious, compassionate, and genuinely interested therapeutic relationship. A Developmental Interpretation Gender dysphoria remains a poorly understood condition. The diagnosis itself is not reliably predictive of an individual's long-term gender identity or whether medical intervention will be the best option. Viewing these issues through the lens of early childhood development paradigms has been helpful. It is hypothesised that some of these struggles stem from difficulties in the relationship with the primary caregiver, often perceived as overpowering or unavailable, compounded by the absence of a third object that could facilitate the separation process. The mourning process associated with separation seems to have been disrupted, leading to the development of a harsh internal voice and reliance on primitive defences, preventing full mourning and impeding identity formation. 

Transition as a Psychic Retreat from Developmental Demands

Laufer (1984) suggests that the task of adolescence is to take ownership of the sexed body. However, with medical transition, this normal developmental process is halted, curtailing options for forming a family and continuing development. Previously, gender identity disorder (GID) referred specifically to the use of puberty blockers to provide a pause in development for children not yet psychologically ready for the demands of puberty as a "Time to Think" (Barnes, 2023). John Steiner (1993) describes a psychic retreat as a defensive organisation that provides respite from the developmental demands associated with the depressive position on the one hand and the fears of fragmentation on the other. I have found that many individuals seek transition as a psychic retreat, offering stability at the cost of the conflicts and turmoil that accompany emotional development. Anxieties related to sexual development often drive the desire for transition.

Psychotherapy for Those with Gender Dysphoria

As mentioned earlier, while being helped to think about oneself might be desired and needed, it is not always welcomed. For example, individuals may feel that the therapist's curiosity and desire to reflect threaten their state of mind, which must be resisted. The therapist's task of observing experience and encouraging thought may raise doubts about the individual's belief systems, leading them to view the therapist's exploratory approach as intrusive and destabilising. Some patients may even perceive the therapist's curiosity as an attempt to undermine their freedom to choose their gender by forcing them to confront their doubts, conflicts, and confusions.

Any attempt by the therapist to explore the desire for transition can be perceived as a cruel form of control. The therapist's curiosity might also be seen as threatening if the patient perceives the therapist as a narcissist—someone more interested in their own admiration than in the patient's experience.

Furthermore, due to the concrete nature of the patient's mindset, thoughts and words are often conflated with actions. Individuals may fear their own imagination and capacity to think just as much as they fear the sexual body, which threatens them with the turbulence of physiological, psychological, and sociological changes brought on by puberty. Because patients often attempt to control their internal world by removing troubling parts of the self and projecting them onto their bodies or external authorities, they may also feel the need to control their external world. For example, some individuals wish to transition to eliminate the fragility they associate with being female or the aggression they associate with being male. I suspect that thoughts of transitioning may often be tied to powerful fantasies of returning to an ideal state where the individual believes they will be protected from unmanageable feelings such as humiliation and shame. In his paper "Time and the Garden of Eden Illusion" (2019), John Steiner describes a fantasy of returning to an illusory ideal relationship with the mother, often connected with a perfect time, place, or relationship before things went wrong.

Challenges as Therapy Progresses

The restriction in the capacity to think and verbalise can deprive the therapist of the material needed to understand the patient. Although patients may present themselves as confident, they often wish to control the therapeutic encounter by limiting access to thoughts that might be experienced as dangerous. Joseph (1975) describes how some patients project a desire for contact with the therapist while simultaneously withdrawing into their own world. Ignoring the fundamental nature of their internal structure and psychological relationships, perverse parts of the patient's self and their pathological internal organisation keep dependent and healthy parts of the self away from the therapist (Steiner, 1982). Rosenfeld (1971) described how the patient's pathological organisation promises to protect the psyche from pain in exchange for loyalty to a narcissistic system.

Understanding the belief system's role in the individual's mind and its relationship to the patient is crucial. Patients may convey that the therapist's attempt to explore their difficulties is distressing, undermining their perceived solution. Patients who communicate threatening aspects of their inner world to the therapist may feel intruded upon when the therapist attempts to provide insight into their projections (Steiner, 1993). When the therapist draws attention to the patient's lack of curiosity or how they project doubts onto others, these attempts may be experienced as an effort to undermine the patient's chosen solution, leading to withdrawal into a defensive position.

The pre-sexual boy, 

I have seen a group of male patients flattened by an internal judge that does not allow room for separation from the object's creativity or development. They are often wedded to an ideal version of the self that does not allow room for ordinary aggression or sexuality. They are ruled by an internal figure that demands perfection and does not allow room for any ordinary aggression or sexuality. They exchange being alive for being in control and watching over themselves and the object. One could say they are not in life but observing life and often spending most of the time on the sidelines of life, sometimes spending large amounts of time online. They often fail to rebel against parental ideals and feel weighed down by expectations. Revenge against their parents is frequently harboured and incubated in phantasy as they wish to kill off the compliant ideal child that they think traps them in a supportive relationship with their parents. In many ways, the idea of killing off the good little boy is a way of killing off in phantasy the compliant child that has to be so perfect and free of conflict or guilt. In many ways, the child has the development task of rebelling against the parents to take responsibility for the developing sexed body. However, this requires a strong enough ego to bear the capacity for guilt and responsibility. Aetiology There is a history of these boys being anxiously attached to the primary caregiver. Several of the boys I have seen have had physical problems. There is a grievance towards the parental couple for failing to provide a perfect body. The physical problems have also caused considerable anxiety, which then interferes with the view of the child as robust and able to separate from the primary object. One might hypothesise that the other understandable anxiety about the child's development impedes the development of a view that the child is robust.

Moreover, they can cope on their own in the outside world. They feel they can only survive if they comply with the primary carers' wishes and ideals. The third object is often looked upon as being either distant or toxic and destructive. Thus, the child fails to separate from the primary object to form an identification with the father. They also fail to internalise a parental couple that can help support the ego and its development struggle. They often present as seeing their trans identity as a solution to an internal problem. I see it in this group as a psychic retreat, a policy that takes a sideways step outside the challenges of development. Puberty introduces the demands of separation from the family and the needs of the adult world, including adult sexual relationships, as part of the transition from childhood to adulthood. These demands require the individual to tolerate conflicts over and for potency. There are often fears of doing harm and being harmed in the sexual act and sexual relations. GIDS was used to describe puberty blockers as a pause for kids who were not ready for the demands of development. My thought is that puberty blockers are a psychic equivalent to a psychic retreat that stops development. Many of the boys in this category are afraid of masculinity. They describe a sort of stereotypical version of masculinity, which is often described as toxic masculinity that is a masculinity that is seen as aggressive, self-seeking and self-centred. The individuals I am describing distance themselves from this sort of masculinity as if they are the antithesis of this model. They adopt a passive attitude in order to distance themselves from anything associated with masculine potency. 

In many ways, the idea of transition is that they would be emasculated as if they would fit in with the mother and distance themselves from any identification with the problematic father. At one level, the idea of transition is related to the concept of killing off the good little boy. At another level, emasculation means that the individual who gives up their capacity to participate in procreation stops the clock as they can no longer take in producing the next generation. In a way, they are like children stuck in never land, avoiding the passage of time. Many kids have problems owning their own desires and wishes for life. They are like in the waiting room of life, with the fantasy that if only they could construct the perfect self or perfect relationship, they would be able to join in life. In therapy, they are often reluctant to use their minds or imaginations, which might be full of desires that a harsh superego judges as unacceptable. Therapy may also involve examining doubts and confusion while they hold onto certain beliefs about what they need to progress in life; these certainties are usually attached to only the fantasy they cling to. In this way, the therapist is believed to push doubts, confusion, and uncertainties back into the patient. The therapist must understand that the exploration process might be experienced as traumatic. The therapist should avoid being provoked by the patient's withholding and suspicion of the process. This active passivity can push the therapist into an overactive stance that the patient then experiences as traumatic. 

Erotised relationship with mother in a folie a deux. 

The fantasy of being the mother's ideal partner excludes a third party as if the infant child believes they are all the mother ever needs. The child triumphs over the realities of separation and smallness by remaining in the position of being the number one king. There is no sense of who the individual is as a separate person. Their mother always admires them in their fantasy, while their father's reality is split off and excluded. This state is excited and narcissistic but then is equally prone to collapse when the individual isn't able to generate the excitement they want, as in their fantasy, they can get right into their mother and occupy her with no separation differentiation. Possible aetiology. First where, there is an eroticisation of the relationship between mother and son. This usually fits into a pattern of failure to negotiate a boundary between a primary object and the infant. It might be because the mother is looking for a love object and idealises the infant boy. There is a thin line between excitement at breastfeeding closeness and over-excitement.

The critical question might be whether the mother sees the boy as a separate person or an extension of the self. To what extent does the mother project into the little boy and overwhelm him? The mother may fail to manage the infant's wishes for intense connection and fear of separation. Sometimes, the mother sleeps with the infant for many years while the father or partner sleeps in bed. The father is excluded or viewed as a figure who threatens the mother-infant duo. The penis is sought after as an excited object that the little boy could steal from his mother. I can become more attractive to my father than my mother. I could be a father's love object, not a mother. Also, becoming a mother avoids depending on a mother. Rather than rely on a mother for love, I become the object I admire. That way, I don't have to depend on anyone else for love, and then I am not in control of the other person. This introduces anxiety about loneliness and loss of love. If you become the thing you admire or need, you triumph over those ordinary anxieties. i.e. rather than depending on someone else to love you. You become the person who is always the one everyone else admires. Technical problems Sexuality and excitement are being looked at as stealing women's position and are seen as providing excitement. And, in some way, act as an anxiolytic from the pain of life. Thinking and being observed is a threat because thinking and observing draw attention to what the individual's actions mean. Minimal capacity to tolerate anxiety or feelings of loss, especially when related to attractiveness or desire for admiration. Going along with this is the absence of symbolic thought. This means there is a restriction on the capacity to imagine. The issue is how to address the underlying anxieties and the tendency to turn therapy into a situation in which the individual is provoked by enacting some display in which the therapist is either going to be provoked into becoming moralistic or joining the individual. Anything goes, and there is nothing to understand. It would help the therapist to free themselves from a sense of responsibility for the outcome. The therapist is just trying to observe and understand the meaning. From time to time, the therapist may either become controlling or allow things to wash over them uncommented on. However, the therapist is always trying to regain a position where they can think about what is being projected onto them. The usual problem in this area occurs when doubt and concern are projected onto the therapist, who is then treated as if they are traumatising or undermining the individual's state of mind. The therapist might be accused of trying to get them to fit in with an idea of their own rather than just accepting whatever they say without judgment, although this is anti-thought. Judgment is often miscast as prejudice when it's thought. Thought is a boundary to action, so it always involves slowing things down and examining them. This might be experienced as a threat to the person who wants to get rid of thought through action and does not want the therapist slowing things down and wanting to think. The other pressure on the therapist is for the patient to act—turning to concrete solutions to eliminate underlying conflicts and concerns. The therapist is the one left with the concern about the planned actions. Then, if the therapist goes to talk to the patient about the problem, they can feel that the therapist is once again just trying to control them. 

Self-hatred, the failure to mourn and the ideal self.

Many of the children I see suffer from long-standing self-hatred based on an identification with and grievance towards a failed ideal object. I have described elsewhere how this can function like a fantasy: "'if only' I could actualise my ideal self "(Evans, 2022). It is an extremely beguiling idea. Indeed, they often picture life post-transition as an ideal state where problems, difficulties, or unwanted parts of the self-have been eradicated. There is a seductive idea that happiness means reaching an achievable ideal state where discomfort and imperfections can be removed. Rather than mourn the loss of the self-ideal as part of the developmental process, some children wishing to transition instead adopt a manic idea that they can repair the damage to their self-ideal, their primary object, and their internalised parental couple through a manic process, by creating the ideal self through transition and eradicating the unwanted aspects of the self that become the target of so much self-hatred. The attempt at the individual and institutional level to avoid pain One of the effects of pain is that it can lead to a degradation of the capacity to think about complicated, multi-layered problems. Individuals and systems under pressure can both fall into the habit of relying on primitive defences like denial, splitting and projection, idealisation and denigration to relieve psychological pain. The problem with these defences is that they tend to produce rather simplistic and often concrete solutions that look to eradicate difficulties rather than offering a model for thinking about and addressing the complexities of the problem. The therapist's job is to understand the patient's suffering while opening a line of communication with the patient in which it is possible to explore and think about the various factors contributing to the patient's problems. The therapist needs to understand that the patient may want to simplify things by narrowing their preoccupations to one problem with one solution, gender, while trying at the same time to interest the young person in the idea of opening things up and thinking about the broader preoccupations and concerns that the individual might have. Slowing things down and thinking about complex psychological problems underlying the individual presentation and symptoms puts everyone in touch with painful issues about the facts of life and realities about our limitations. In contrast, the children and young people with gender dysphoria whom I see are particularly prone to using paranoid-schizoid defences, otherwise known as 'black and white' thinking. They divide the world between ideally good and bad persecuted states of mind. In conclusion, we all need beliefs that provide a structure for thinking about ourselves and our relation to the external world. However, mental health is based on the ability to modify our beliefs in the face of our experience. This involves mourning the loss of previously held beliefs (see Britton,1989). Rigid and fixed beliefs are often used to defend against anxieties about uncertainty and confusion. Under pressure associated with development, adolescents may look to fix the upheaval they are experiencing by organising themselves into an identity detached from their sexual natal body. They see their body as the source of confusion and threatening demands of the adult world and adopt this narrow preoccupation to control their underlying feelings of confusion and turbulence. When such an individual looking for psychological control (by splitting and projection) meets a clinical team (GIDs) influenced by affirmation, the former finds the support they are seeking. An unquestioningly affirmative team supports the patient's belief that they will feel comfortable if they can eradicate troublesome aspects of their natal sex, parts they believe contain unwanted elements of the self. Rather than being helped to give up their idea of self-created perfection, patients are encouraged to think they can become the ideal self of their dreams. In this way, not only is the individual locked into concrete thinking, but the relationship between the individual seeking help and the service is also dominated by concrete thinking. A "confusion of registers", as described by Perelberg (2019), can arise when analysts and patients are prone to get caught up in mistaken symbolic communication and concrete action. The relationship lacks any ability to think symbolically about the meaning of symptoms: the concrete solution sought by individuals matches the concrete aspirations of the trans-affirmative ideology. Thus, individuals who suffer from an intolerance of themselves as a psychological problem are treated concretely by having their healthy bodies treated medically. Any attempt to slow things down and think is often perceived as threatening a manic solution with hidden long-term costs. Careful thought is an attempt to resist the temptation to swallow simplistic but possibly inadequate explanations and instead take time to think. 

Marcus Evans