MOURNING THE LOSS OF THE IDEAL SELF: SHORT-TERM WORK WITH A TRANS PATIENT POST-TRANSITION
Abstract
Many individuals who have been through transition struggle to obtain the necessary medical and psychological support. This paper explores the importance of psychological support for post-transition individuals. In my experience, there is a subgroup of patients who struggle to come to terms with life post-transition, particularly the losses involved. They remain stuck in the mourning process. There is a loss of fantasies regarding an ideal transition, and the gap between the hoped-for transition outcomes and the post-transition reality can be painfully large. In addition, issues that the transition was meant to address remain in some form for some people, and they may also be haunted by misgivings about how the transition occurred. This paper employs a heavily anonymised composite case to illustrate and elaborate on how these issues emerged and were dealt with in the context of a psychotherapeutic process. Working through issues that led to transition and grievances about perceived and actual failures in care from the past allowed the patient to mourn the loss of her pre-transition image. The patient was able to come to terms with the reality of her transfer from male to trans-female and her body and life post-transition and to shift from a preoccupation with the past to move on with her life.
There has been a rapid rise in the number of young people presenting to gender services, with referrals to the (now closed) Gender Identity Development Service (GIDS) at the Tavistock and Portman National Health Service Trust growing from approximately 50 in 2009 to over 2700 in 2019/2020 (Cass, 2022). According to advocates, patients who undertake medical intervention for gender dysphoria report improved body satisfaction and improved psychological symptoms (Costa et al., 2015; van de Grift et al., 2017). Long term, a good transition involves being able to pass as a member of the opposite sex and live a comfortable life. Unfortunately, there are no long-term outcome studies of individuals who commenced transition as minors to support this claim. In addition, once corrected, a large, long-term study of post-transition adults in Sweden (Bränström & Pachankis, 2020a, 2020b) found no psychological benefit from surgery or hormones. There is also a growing number of people who regret their transition, posting on YouTube and various social media sites. The percentage of those who regret or de-transition is unknown (Cohn, 2023), as is the number who have trouble coming to terms with life post-transition. However, one of the few long-term outcome studies of adults indicates that significant mental health support is still needed after transition. This (also Swedish) study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts and psychiatric hospitalisations among sex-reassigned transsexual individuals compared with a healthy control population (Dhejne et al., 2011). This indicates that post-surgical transsexuals are an at-risk group that needs long-term psychiatric and medical follow-up. It should also be noted that patients followed up by Dhejne et al. (2011) had undergone a rigorous two-year evaluation and treatment preparation process beginning with sterilisation (Dhejne et al., 2014), a much more stringent screening process than currently recommended by, for example, World Professional Association for Transgender Health (Coleman et al., 2022).
Many in this group were driven by the belief that these medical interventions would address their difficulties and were unprepared for these interventions' inevitable limitations. Some became suicidal when they discovered that their difficulties had not been dealt with in the way they had hoped. Similar outcomes have been described in several case histories in the literature, for example, D'Angelo (2018), Ayad et al. (2022) and Withers (2020), and raise ethical concerns regarding the current medical treatment of transgender individuals and those with gender dysphoria (Levine & Abbruzzese, 2023). These reported harmful outcomes are in contrast with unsupported claims that medical interventions are needed to prevent suicide; such claims are not backed in research studies or systematic review (Baker et al., 2021; Cass Review, 2024; D'Angelo et al., 2021; Ruuska et al., 2024).
Several needs are reported by those with difficulties adjusting post-transition. Some are upset by the gap between reality and the physical changes they had hoped the medical interventions would achieve. They had thought that their bodies would align with the image they created in their minds but then realised their transition was only skin deep. Some experience anxiety around passing as someone of the opposite sex or over impaired sexual functioning, for example, in a recent (incomplete) follow-up of the carefully vetted ‘Dutch cohort,’ whose protocol required lifelong extreme gender dysphoria for inclusion, ‘nearly a quarter of the participants have felt that their bodies were still too masculine, and over half have experienced shame for the “operated vagina” and fearful their partner will find out their post-surgical status’ (Abbruzzese et al., 2023, p. 682).
More generally, an individual who has undergone a medical transition is faced with the losses brought about by medication or surgery, as well as the gains. The painful grieving process includes mourning the loss of the ideal body and imagined existence they had created in their minds before their medical transition. They may retreat into their fantasies to escape from the difference between the experience of the reality of the body after medical intervention and the body they wished for. However, escaping into the mind provides only temporary relief because the body is a constant reminder of the limitations of the fantasied solution and the difference between fantasy and reality.
The gap between the aspiration of transition and what transpires, especially as time passes, can also leave the individual with feelings of disappointment or anger at being misled or rushed into medical intervention. The patient may struggle with questions about early decisions and loss of functioning. Children who have not experienced adult sexuality have no way of knowing what they might be giving up when they start medical interventions that might eventually lead to them becoming infertile, as puberty blockers in studies almost always lead to cross-sex hormones. Children's views about having an active sexual life or becoming parents often change over time (Abbruzzese et al., 2023).
Individuals may harbour grievances towards medical professionals, online groups and parents who supported their transition, who supported the individual's belief that difficulties might be improved by physical change towards an ideal. Although parents and medical professionals may have been responding to pressure to remove the cause of the psychological distress caused by the gap between the given and the wished-for gender, patients may feel let down, believing that insufficient time and thought were given to exploring the reasons for their wish to transition. Some individuals describe having been encouraged by professionals and support groups to keep moving forward on the medical ‘conveyor belt,’ with very little in the way of psychological assessment (Baxendale, 2023; Bond, 2023). In the United States, one can even obtain hormonal treatment without a mental health evaluation, a process called ‘informed consent’ (Cavanaugh et al., 2016). This rushed feeling is key in the composite case study described below. These grievances can interfere with the process of mourning the losses brought about by transition and moving on with life.
Many individuals also report rejection by online groups supporting transition when they started to raise doubts or disappointment about the transition. The transition might have already strained family relationships, and leaving or disagreeing with the online groups can result in their feeling psychologically unsupported and homeless. Some clinicians emphasise psychological stress caused by a lack of social acceptance, ‘minority stress’ (Levine et al., 2022), which in this case can be rejection from the online community due to self-doubt or due to family disagreement about undergoing transition. Doubts regarding transition are often dismissed as being a version of internalised transphobia that needs to be ignored or overcome rather than the expression of legitimate concern about the idea of transitioning (Mondegreen, 2023a, 2023b; Vandenbussche, 2022).
It has been long known that many so-called ‘minor regrets’ arise after surgery, including disappointment relative to expectations, conflicts with families, pain, complications and losses of partners or jobs (Pfäfflin, 1992). This might be resolved with counselling. However, many patients report to me that they feel support services are not interested in their ongoing physical and psychological difficulties and that adequate post-transition care is unavailable. The need for ongoing medical and psychological care for this post-transition group is not widely acknowledged, even to those planning surgical intervention.
Case study
The case study described here aims to raise awareness of the situations in which some patients find themselves after transition and to illustrate how prior and transition-related issues can repeat with the therapeutic process post-transition. There are many similar clinical features among trans-identifying or gender dysphoric individuals who have unresolved pre-transition difficulties, doubts and disappointments about their transition and similar challenges in mourning their losses. Difficulties with the complicated psychological work of letting go of past identities and mourning the loss of beliefs and states of mind can interfere with their moving forward to grasp new challenges. I have found there is a need to open things up and think about these individuals broadly, away from a narrow and exclusive preoccupation with gender. The therapist embarks on this broader therapeutic process to explore the individual's life: who are they, what are the family dynamics, how does their mind work and can they reflect on the functioning of their mind? The progression of therapy for a composite anonymised patient, ‘Paula,’ discussed below, provides an example of how psychological support can help an individual overcome their conflicts and feelings about their transition, throw light on their current conflicts and predicaments and assist them in deciding how to approach their lives in the future.
As this is a case study, there are ethical considerations around confidentiality. There is also the long-recognised conflict of interest between the patient's right to confidentiality and the need of the profession to develop ideas through the study of cases (Gabbard, 2000). To protect patients' privacy, the case described here has been anonymised by combining aspects from similar histories of a small group of patients with similar concerns and changing non-essential details: the original patients will be unable to recognise themselves. This anonymisation goes beyond what is described in Gabbard (2000), where only the patients can recognise themselves. This approach to protecting patient privacy also introduces more subjectivity to the paper, as there is not only a choice of material to include but also of which details to modify.
When addressing the patients making up the composite Paula, I always used their chosen name and female pronouns and do so in this paper (I will use the name Paul for some of the historical data pre-transition). However, keeping the corresponding natal child (‘Paul’) simultaneously in mind is important. The natal child Paul is a reminder of Paula's natal sex, and this aspect of the self and what it represents still exists, even if it is not wanted or viewed (by Paula) as part of her history.
Paula was a 28-year-old male-to-female transsexual who referred herself for psychotherapy due to doubts about her transition. In her teen years, Paula commenced on puberty blockers and cross-sex hormones, followed by sex-reassignment surgery in her early twenties. She contacted me in her late twenties, expressing some doubts about the process of transition, including regrets about losing sexual function.
Paula said she liked some of the things I said in an article and wanted psychotherapy to help her resolve some of the dilemmas and conflicts about her past to move forward with her future. She had started questioning some aspects of her transition in her mid-20s after coming out of what she described as a euphoric state associated with the transition. She had not been prepared for the difference between her expectations of the body and life transition and her resulting actual physical and psychological reality. She felt she had been placed upon a ‘conveyor belt’ and rushed to transition by people in positions of authority, who may have had their own motives for backing her decision to transition. This left Paula with doubts about the decision-making process leading to her transition and whether those in authority acted with sufficient care. Paula suspected she might have been used to support people's ambitions, which was the source of an ongoing grievance, inhibiting her capacity to move on in her life. At no stage did Paula feel that undergoing transition had been a mistake.
First consultation
Paula (whose given name was Paul) was conceived because of a one-night stand that her mother, Jan, had with Paula's father. Apart from this information, she never learned anything about her father. During early childhood, Paula and Jan lived with Debra and her husband, John, as part of a religious community. Paula described herself as being involved in the sect for most of her childhood, attending chapel and Sunday school until her late teens.
Paula (as the boy Paul) formed a close relationship with John, even though John was a binge drinker and had a temper when drunk. They used to share an interest in fishing. Learning from Jan that John had been having an affair with a married man and was moving out of the family home was devastating. Paula remembered overhearing angry conversations between Jan and Debra about John and weak men. I said this must have disturbed Paula as (then) a young boy, hearing men described as weak and unreliable. Paula said that she had not thought about it in the long term. However, she did remember getting upset whenever she got a bad report.
I said it sounded like the incident with John was quite a blow. It was as if the boy Paul felt they had lost a relationship with a man to relate to. Paula said she was aware that most of the children in the sect and at school were brought up by mothers and fathers and had felt that she was missing something.
Paula said she was anxiously attached to Jan: ‘She was more like a sister to me growing up’. Paula was teased at school for being interested in traditionally feminine pursuits such as dance rather than sports. Paula said she hated the boys who bullied her and described them as demonstrating ‘toxic masculinity’. I said that Paula did not seem to have had any good model of masculinity and that it must have been difficult growing up knowing that masculinity was seen as unreliable. Paula agreed with this, saying that she did not mix with the boys at school but tended to spend more and more time in her room.
Upon reaching puberty, Paula was disturbed by her masturbation fantasies about homosexual sex. I pointed out the way Paula seemed to split the part of the self that wanted to be distanced from ‘toxic masculinity’ and weak men and the part that was attracted to men. Paula agreed, saying she felt ashamed and thought her mother and the sect would disapprove. I said they would fit Paula (then the young man Paul) into the weak men category. Paula said she remembered feeling self-conscious and ashamed during her mid-teens and again mentioned spending more time online in her room.
Paula remembered coming across pro-transition sites and developing the idea that transition was the only solution to her problem. She started discussing her ideas about the transition with her mother during her late teens. She was surprised her mother encouraged to pursue the idea and arranged for medical consultations. Paula was also surprised that the medical practitioners seemed very keen to support her wish to transition. Paula described the feeling of being on a fast-track conveyor belt, with encouragement by practitioners and online supporters without much or any exploration of motivations, expectations, hopes or whether there were any reservations towards increased medical interventions. At 17, Paula started on oestrogen, which greatly excited her. Then, Paula underwent surgery upon reaching her 20s. I told Paula that the fast-track system seemed to exclude any question or doubt in Paula's or anyone else's mind. Paula nodded, saying she had felt like she was skateboarding downhill without knowing how to stop or get off. The male surgeon who performed the surgery had reassured Paula that the surgically created genitals would function perfectly. However, the surgically created vagina needed constant attention and was often uncomfortable and painful. I said I thought the physical sensitivity was a painful reminder of the gap between how she pictured her transition and reality. Paula looked upset when saying that she regretted not being able to contribute to having children.
I was conscious of Paula's openness to discussing these painful issues during the consultation. I said we were also in danger of going too quickly on an exploratory conveyor belt, where my agenda would dominate. We needed to take some time to think about what Paula felt the therapy might help achieve. We agreed to meet twice weekly in the chair.
Discussion of the consultation
I thought Paula had difficulty separating from an overly close relationship with her mother. It was as if, as a child, Paula felt they both lacked an internal structure that could get them through the separation process. This reminded me of Paula's missing father and the loss of John. In identification with her mother, Paula seemed to view men as weak and unreliable. Paula also agreed that she saw her homosexual desires as the boy Paul as unacceptable, placing her, as a young man, into the weak (unacceptable) male category. I thought the idea of transition seemed attractive because it allowed Paula to maintain an interest in men without being seen as homosexual. Thus, Paula could retain her mother's love and admiration as a transwoman rather than feeling despised as a homosexual man. (Note that this is the opposite of transgender identification causing minority stress; here, it is homophobia, gay minority stress, so to speak, driving Paula to transgender identification; Bell, 2020.) This, too, made me think of her father's absence and overly close relationship with a mother who treated her more like a sibling than her child. I thought Paula's wish for therapy seemed related to the hope that she could be helped to find her own identity, although I thought there was also a drive towards repeating past patterns of behaviour.
Second consultation
Paula said she had been upset after the last consultation and had many issues she wanted to discuss and think through. She said she had doubts about how things that had happened to her in the past prevented her from moving forward. I said I thought she could not let go of these misgivings, doubts and questions until they had been thought about and understood. Paula agreed with this and again said she was surprised at the speed with which the medics encouraged her transition. I said I thought she felt they had lost touch with her as if the medics' preferences had taken over the consultation. Paula said the clinicians seemed taken by their cleverness at performing these operations. I was reminded of how she came across me in an article. I said there might be a question about whether I was one of those clinicians driven by self-interest. We might be in danger of repeating the past patterns by going too quickly into therapy without thinking about the goal, like the conveyor belt, with no thought of how Paula would be left feeling.
Paula said that during her mid-teens, she developed an avatar of herself. This very feminine woman loved floral dresses and always seemed serene. I said this seemed a long way away from the anxious teenager who was confused and conflicted about sexuality and sexual preferences. It was as if she yearned to be seen as this serene figure with no problems. Paula nodded, saying she did not like feeling anxious and worried about herself.
Paula repeated that the sect was strict and clearly against homosexuality. She thought this was one of the reasons her mother supported her in her thoughts about transition. I shared my thoughts that she did not want to undermine her mother's membership in the sect. Paula said she did not believe in the church's teaching but knew the sect's support was important for her mother. She did not want to do anything that would upset their place in the congregation. Paula said that, even now, she speaks to her mother several times a day and gets anxious if she cannot get through for any reason. I said she seemed to play the role of an endlessly supportive child for her mother, one who believed any separation seemed to threaten a sort of psychological collapse for them both. I was also conscious of how Paula watched me as if she felt I was an unstable figure who had to be watched closely. She talked about her fear that neither she nor her mother could have any form of separation. I said this was also an issue in the therapy, as she sometimes looked at me to take the lead as if she always wanted to ensure that the sessions provided me with what I wanted. Paula said that she always preferred to follow others' lead.
Third consultation
In the next session the following week, Paula said that she had felt terrible after the last session and that it had taken her some time to recover her composure. I said that I thought there was a danger that this therapy was going too quickly, leaving her feeling that she had been overexposed and uncared for after the sessions. Paula said that this was just part of the process and that if she wanted to improve, then she had to tackle the difficult things that haunted her from her past.
Paula said that when she thought about dating men, she worried about them seeing her body and wondered whether she would pass as a woman. This was one of the reasons that prevented her from establishing a longer term relationship. She worried men would start having questions about her as she got to know them. Paula said she would tell them eventually but feared rejection. She wished for intimate relationships but was also afraid of the shame of them looking at her scarred body. I said it was a bit like therapy; she wanted to explore some of the difficulties she had to overcome. However, she felt that this involved exposing painful and challenging areas of her life and exposing her to considerable shame. Paula sometimes despaired that she would overcome these hurdles and have a relationship.
Then Paula brought up a repetitive pattern of behaviour. She told me she would get extremely drunk, picking up men in a pub and then going to their houses for sex. She did not know any of these men and worried she would be in danger. She often felt ashamed after the event. I drew a parallel with the professionals who took over the consultations, with Paula aware that the other person's goals had taken over her own. Both parties seemed to act as if they were on the same page, while Paula observed that both parties seemed to be carried away by the excitement that left her vulnerable to mistreatment. Paula said she could always nudge and seduce others into agreeing to give her what she wished for.
Discussion of the sessions
As Paula contacted me after reading about my opinions about transition for children, about which there is increasing professional disagreement (Block, 2023), she may have expected me to endorse her critical view of the therapists whom she felt had rushed her into medical transition. Unconscious enactments, such as when the individual seeks a heroic figure to rescue them and endorse their view that failed ideal objects have let them down, can dominate and endanger the therapeutic work.
Enactments in psychoanalytic psychotherapy and the accompanying ethical concerns are inevitable and part of the process. On several occasions, Paula's passivity in sessions would nudge me into taking a more active stance, which she would quickly encourage. And I thought Paula submitted herself to a cruel examination process with me that revealed underlying scars and damage, with her often saying that she was left feeling upset and disturbed after the sessions. Yet she continued. The examination process was always in danger of fluctuating between being either blind to the problems and seriousness of Paula's underlying difficulties on the one hand or becoming a reckless form of exhibitionism on the other hand. I was caught between wanting to understand what was inhibiting the mourning process on the one hand and respecting her defences on the other. I tried to recognise this tendency towards enactment when it occurred and to slow down the exploratory nature of the sessions as we moved from the initial consultation (which inevitably contained some essential information gathering) to ongoing sessions.
In addition, I thought Paula's wounds represented shame from someone witnessing the effect of her self-hatred. Bion's, 1959 paper ‘On Arrogance’ regarding the transference can be seen as a critique of the ‘moralism’ in the therapist's actions of ‘translating from the unconscious into the conscious, allying oneself with the ‘healthy’ part of the patient's ego and looking ‘down upon his patients and colleagues’ for madness’ (Civitarese, 2021, p. 252). This issue and that of enactment are more fraught when serious harm has already been done to the patient or the patient's relationship with others and even more so when the damage has come from therapists.
A critical session 6 months into the therapy
Six months into therapy, Paula started the session extremely angry, saying she felt the sessions left her feeling upset and exposed. She said that she was thinking of stopping the sessions as she was not sure they were helping. I said that I thought she felt I was exposing her difficulties and leaving her to manage her feelings after the session. I said that I thought she felt as she had with others, that I was pursuing my interests with no concern about how this left her dealing with the feelings raised.
After some time, Paula calmed down, saying that she often felt she contributed to her mistreatment by encouraging others to take over the agenda. We examined how her passive approach to the sessions left her somewhat vulnerable to others' agendas, which she encouraged but which then led to her becoming suspicious of the other person's motives.
Discussion of the critical session
Throughout the therapeutic process, Paula supported my interest in her. She knew I was keen to understand transgender-related problems, and she went along with this. Simultaneously, I felt she suspected me of being just like other narcissistic figures from her past who had used her for their purposes (this group of patients also often reports a history of bullying in childhood). In this session, Paula was able to move out of the position of someone who sees herself as supporting others while harbouring a grievance about mistreatment. Instead, she challenged me directly about my mistreatment of her. Her more active stance meant that she had to be able to tolerate her fears of my retaliation and her feelings of guilt about harming my view of myself. I thought this was an important developmental step, as Paula was allowing a separation to form between us.
The ability to tolerate guilt about her part in the transition was also important. Looking at grievances and disappointments, Paula's approach now also involved thinking about her role in these dynamics, including her role in getting on the transition ‘conveyor belt.’
Paula tended to try to leave problems behind but found she was repeating patterns from previous relationships—the medical transition appeared to be one way she was trying to leave problems behind. Developing tolerance of guilt allowed Paula to examine, from a more objective perspective, the part she played and the role and responsibilities of others involved in her transition and to separate the two.
As the therapy progressed, we were able to see the role Paula's passivity played in encouraging others to take over her treatment. Her passivity encouraged others to take over the driving seat, as she could fit in behind the surgeon or therapists' tendency to get carried away with their craft, losing sight of the patient in front of them. We spotted this pattern and examined how I was often encouraged to take the lead in the session, leaving Paula looking on. Doing this would (again) result in a person in authority taking over, again suspected by Paula to be doing so for their own reasons while she watched on from the passenger's seat. It was as if she would encourage me to put her on a skateboard and push her down the hill recklessly and dangerously while at the same time viewing me as another irresponsible and uncaring person in a position of responsibility. This repeated pattern increased Paula's feeling of being unloved and uncared for. There was also hidden self-destructiveness as if, in phantasy, she would say to the object after some act of reckless abandon, ‘See, look what you made me do’. Aggression towards me was present as well: while Paula was polite, reasonable and grateful on the surface, at another level, she saw me as a self-centred individual who did not have any genuine interest in her.
Over time, Paula could relinquish some of her grievances towards others over how the transition had taken place by accepting her part in this repetitive cycle of relating. The ability to acknowledge this pattern allowed Paula to spot when she was starting to enact this dynamic and to take more responsibility for the direction of her life and her relationships. In practice, this amounted to her attempting to use thought as a brake in situations which resembled the ‘conveyor belts’ she and others had described and resisting the tendency to get into no-holds-barred relationships. Paula could recognise that she would likely relinquish her agency and feel coerced into no-holds-barred relationships.
There was also pressure in the countertransference related to another issue we examined, Paula's difficulty negotiating her relationship with her mother. Paula felt responsible for her mother and had difficulty sustaining a separate life and identity. This was manifested in the therapy, as Paula watched me intensely in the consulting room. She was highly attuned to any gesture or movement as if it might indicate that I was frustrated, bored, or, as mentioned above, unstable. I was like an unreliable mother who had to be watched continually to ensure that I did not drop the infant. Paula's vigilance also reflected her sense of the threat posed by the thinking process; it seemed I had to be closely monitored to ensure we were completely in tune. Any indication I was separating would be evidence that I would drop her experience in preference for my thinking, which would be experienced as a betrayal rather than as helpful additional thinking from a different perspective. Thinking about Paula's experience from a separate point of view (in conversation with myself, for example) seemed to be a threat to her subjective experience. This difficulty with being viewed objectively appeared to be related to Paula's difficulty with separating from her mother. In the following theory section, I consider her early childhood development and the lack of a third object due to the absence of a father.
I felt under constant pressure to reassure or respond reassuringly and found it challenging to find the mental space to think for myself. Over time, I found space to think for myself, including understanding Paula's subjective experience using a two-stage process, which first involved finding a space to make room for Paula's subjective experience and then, second, for more objective ways of thinking about her presentation, motives and beliefs. This development was accompanied by Paula's ability, as mentioned earlier on, to stand up to me and disagree without feeling that she had caused some serious psychological damage. A shift in the therapy accompanied this sense of freedom, as we moved from a preoccupation with grievances towards the past figures that she felt had betrayed her, to issues concerning her future life. In Paula, this shift was accompanied by a more general shift from preoccupations with the past to thoughts about the future.
Eight months into the therapy, Paula said that she planned to end the treatment as she felt she was in a better place to get on with her life, and we planned to end on the anniversary of her beginning. Towards the end of the therapy, we discussed Paula's feeling that she had missed the involvement of a mother and a father who could have supported her development. Such a situation might have protected her from her over-involved relationship with her mother and Paula's excessive wish to support her, on the one hand, and the influence of powerful male figures like the surgeon, on the other hand.
For Paula, these powerful male figures often promised omnipotent solutions to eradicate problems. She would go along but subsequently harbour questions about whether she had taken the right action. In particular, the view that someone else's ambition had taken over when she tried to get help often became the source of a grievance, and this grievance seemed to become the locus of interference in the transition-related mourning process. Paula had then been unable to relinquish old identities and move on.
THEORY
I have seen several trans-identifying or gender dysphoric individuals with difficulty coming to terms with life post-transition, who share many of the clinical features illustrated by Paula. Some in this group have a fragile ego structure and adopt an ‘if only I was a girl or boy idea’ that promises to protect them from psychological pain (Evans, 2022). It appears they had formed anxious attachments to their primary object, often the mother, and had difficulty internalising them to develop a good internal object. The absence of a good internal object supporting them in reflecting upon themselves, leads to problems of separation and differentiation. Importantly, the third object (psychically the father/partner), as emphasised by Britton (1989), can support the mother-infant couple while providing room for separation and thought, and the model of the parental couple coming together to think about the infant can be internalised, supporting the ego in its development. This strengthened ego can tolerate feelings involved in separation from the primary object, such as conflicts between love and hate, anxiety, jealousy and guilt.
Over time, the model of the three-person relationship also provides a model for looking at relationships from different points of view. The infant's subjective experience of being understood emotionally in the primary relationship combines with the experience of being observed and thought about from an objective perspective by the third object. This helps the infant to shift from reliance on concrete thinking, in which there is no differentiation between self and object, towards a capacity for symbolic thought. Separation from the object also means seeing the object as it is and being observed by it. This, in turn, requires the capacity to tolerate the shame of being seen (Steiner, 2011). However, the third object (often the father) might be absent or experienced as distant or intrusive for other reasons (the oedipal situation can instead be experienced as an unwelcome intrusion, for instance) and symbolic thought and the ability to be viewed objectively might not have developed. (This seemed relevant for Paula's therapy as noted above.)
Fragility in the sense of self can lead to a wish to hold onto an ideal version of the infant-mother relationship and coupled with the absence of third object support for the mother-infant couple, problems in separation-individuation can arise. The relationship may instead be saturated with projections from the infant to the mother and vice versa. The individual may oscillate between a wish to get inside and take over the mother's identity or feel that they dis-identify with the mother but do not wish to identify with the father. This leaves them in no man's land, lost in the gap between the parents.
Paula's medical transition seemed based upon the idea that she could get rid of her masculine identity, associated with failed male figures and a reminder of her separate existence, to join her mother's identity. I believe Paula also harboured a grievance towards her father for abandoning her mother and towards her mother for making the little boy Paul feel like an unwelcome reminder of an abandoning male figure. In some similar cases, I have also observed grievances against parental figures perceived to have failed to provide the child with the body or mind they wanted. A repeated cycle of grievances and fantasies of taking revenge against parental figures frequently appears to contribute towards the wish to transition, often associated with the wish to punish the failed ideal object through changing their gender. These grievance patterns and revenge fantasies may repeat with medical professionals.
For individuals with an overclose relationship with a maternal object and the lack of a third party's help with the process of separation, a specific pattern could arise in therapy. Such patients sometimes search for a paternal figure who could provide space for them to develop an idea of themselves. However, the exploratory process is painful, and the internal object can be felt to be so damaged (e.g., Paula's scars and her unresolved difficulties) that they need the paternal object to be a phallus, which is a powerful masculine figure that promises to repair all damage, rather than an ordinary penis (Birksted-Breen, 1996). When the idealised object fails to provide the necessary cure, a powerful resentment develops. This grievance may remain hidden for some time. However, it starts to act as a block in the therapy and for the process of mourning.
Steiner (2011) has described how preoccupation with grievances and wishes to exact revenge towards failed ideal objects can interfere with the mourning process and lead to a stuck individual. He also describes how the individual may be haunted by reproachful figures in the internal world who demand concrete solutions to psychological problems. One such solution is to pursue the idea that the lost ideal self and object can be restored rather than mourned and relinquished. In part, this failure is due to the concrete thinking of the melancholic, which creates a major obstacle to the completion of mourning.
While the factors that enable symbolism to develop are yet only partially understood, it has something to do with the work of mourning, which requires the object to be recognised as dead so that the libido can be withdrawn from it (Freud, 1953). Freud recognised the importance of this move but was also aware that such withdrawal of libido could be excruciating and demanded a ‘great expense of time and cathartic energy’. We can understand this disinvestment better if we consider this process involving reversing projective identification (Steiner, 1996). While mourning, it is not just the libido but parts of the self that return to the ego. Elements of the self previously located in the object through projective identification are returned to the self. Sometimes, the disinvestment seems to leave wounds behind, as if the object is torn away from the self, and the pain will need to be repeated as each of the memories of the lost object is subject to the verdict of reality. However, when this dis-identification is allowed to happen, a new and enormously important capacity to symbolise becomes available (Segal, 1957), which allows us to participate in the world of the imagination we then have. These individuals can then dream, use their imagination and make symbolic rather than concrete repairs.
In the therapeutic relationship, the individual is offered an opportunity to explore the dynamics of internal grievances and phantasies of revenge, which interfere with the mourning process. This exploration may include an idea of revenge in which the individual attacks the external object. The individual can take out their disappointment with the therapist and the therapy for perceived or real failings in the therapeutic process. When the individual faces the therapist with feelings about the failure of the therapy to provide an ideal solution, it can lead to remorse and guilt and relinquishing old grievances. The mourning process requires the individual to move from the internal grievance towards a concretely experienced failed ideal object and then towards a psychological separation between self and object. Progress in the therapy relies on the analyst's ability to help the individual develop a mind of their own, including their observation of the therapist and their shortcomings. Using exploration and thinking to work through feelings of disappointment (with what the therapy can achieve and with perceived slights and misunderstandings) can help the individual's process of separation and differentiation. This, in turn, allows a shift from concrete thinking associated with an undifferentiated relationship between self and object towards psychological separation. This development leaves room for symbolic thought: reparation can be made symbolically concerning future object relations while mourning the loss of the ideal object. This process can also assist the individual in leaving behind preoccupations with disappointments about the past and the present, instead becoming preoccupied with struggles involved in the future.
Some common misunderstandings and challenges in the therapeutic relationship
For individuals who have difficulties coming to terms with their transition, internal conflicts may be externalised and repeated in the relationship with the therapist. These repeated patterns can undermine the therapeutic goal of helping individuals understand their conflicts to make more informed life decisions but can also be part of the therapeutic process as occurred in Paula's composite case history. This is an additional reason that it is important that the patient and therapist share an understanding of the role of the therapist and the therapy process post-transition (and therapy goals), as misunderstandings about either can echo earlier misunderstandings with medical professionals who encouraged or provided medical transition, and the resulting grievances.
If a previous clinician lacked care or thoughtfulness in encouraging a path to medical transition, another common pitfall can occur. While establishing what took place and who contributed to decisions can be an essential part of any therapy, this can put unconscious pressure on the therapist to actively condemn these failed figures from the patient's past and place the therapist in the position of the ideal figure sought by the patient. This role can blind the therapist to the risk of repetition in the current relationship and prevent them from helping the individual explore the impulses and motives driving their states of mind. If the therapist is identified as a heroic figure who can point out deficits in their colleagues, the problems of previous relationships with authority figures may be repeated in the current therapeutic relationship. This identification leads to the belief that this ideal figure, the new therapist, can provide the wished-for ideal therapy, unlike the failed ideal figures from the individual's past.
In addition, individuals with grievances sometimes want the therapist to join in their belief that trauma or injustice is the sole source of their psychological difficulty. The therapist's endorsement of this interpretation is treated as if it will help them restore the ideal state of mind they believe has been taken away by the trauma. However, the therapist has the job of understanding the nature and role of these beliefs, as the grievances may interfere with the individual's ability to surmount the loss of the ideal and move forward in their lives, and dealing with them may be key to the mourning process, as described earlier. If this dynamic is not understood, it can lead to conflicts between the therapist and the patient.
DISCUSSION
Paula's case is relevant for some de-transitioners who have reported trying to suppress their doubts for relatively long periods. This includes those regretters who reported being afraid to share their doubts before surgery due to fears they would be prevented from obtaining surgery (Kuiper & Cohen-Kettenis, 1998). They pushed ahead with medical interventions, believing they were solving their problems. Although an initial euphoria, sometimes described as the honeymoon period, often accompanies social and physical transition (Nobili et al., 2018), some either immediately or eventually feel disillusioned because their interventions failed to address deep-seated underlying difficulties. For instance, for Paula, the transition was a repetition of her tendency to give the driver's seat to others whose goals did not align with hers and then regret it. Her transition was also a response to not having men she respected with whom she could identify. Paula felt shame due to how she looked post-transition; the physical outcome of the transition was not as she had been promised.
Overvalued beliefs about transition can break down when it becomes evident that the individual's expectations are based more on wishful thinking than on a realistic appraisal of what medical transition can and cannot achieve (Levine et al., 2022). Thus, belief in the treatment can be eroded over time as the difference between the picture of transition developed in the mind and the reality of post-transition life becomes apparent, such as difficulty ‘passing’ as someone from the opposite sex or limitations of sexual functioning.
When doubts start to erode the feeling of certainty, they can lead to community rejection and a psychological collapse or depression, with the individuals feeling psychologically homeless. They may not feel comfortable with their gender identity, and they may feel that they have appropriated an identity of the opposite sex, leading to guilt. They might feel like they do not have a place in their bodies, gender identity or families and act as if they wish to remain invisible to the outside world. These experiences may stir up long-standing feelings of being unwelcome, ungrateful, displaced or guilty about the damage done to familial relationships.
In time, some may decide to de-transition (Jorgensen, 2023). Some, like Keira Bell (2021), may regret their transition and feel angry that they were not given a more thorough psychological evaluation beforehand; some wish for help to socially de-transition and live their lives in keeping with their biological sex. Others may believe they have to make the best of their transition as, given the extent of the medical intervention, they see no other option. Some post-treatment transitioners do not necessarily wish to de-transition but have difficulty accepting the demands of their life post-transition. [Correction added on 21 August 2024, after first online publication: In the preceding sentence, ‘transitionary’ has been corrected to ‘transitioners’, in this version.] Although those in the latter two groups may decide to endorse their physical changes, they may still struggle to mourn the loss of previous identities. Whatever their feelings about their treatment and the process involved, lives are complicated post-transition, and many are likely to need ongoing support and help.
The patients in the composite, and others I have seen, had a fantasy of transition: that individuals can rise above unwanted aspects of themselves, aspects they identify with their body and its failings (Evans & Evans, 2021). However, this state of mind minimises the potential downsides of transition issues, and unresolved issues can even intensify. These individuals' difficulty mourning the loss of the ideal self is re-experienced, as the body they were promised pre-medical intervention is not matched by the body they experienced post-surgery. Psychotherapy may involve, as in the illustrative case here, addressing issues before transition and those which occurred during transition. It can often help individuals stuck in the mourning process understand the difference between the ideal that was wished for and the reality and enable them to turn their focus to the future and move forward in their lives.
ACKNOWLEDGEMENTS
I thank the peer reviewers and the editors for their suggestions and criticisms to help improve the paper. I would also like to thank J. Cohn & Susan Evans for their help in editing this paper.
Biography
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MARCUS EVANS is a Psychoanalyst, Registered Mental Nurse and Fellow of the British Psychoanalytical Society with over 45 years of experience in mental health. He served as a consultant psychotherapist and mental health nurse and held the position of head of the nursing discipline at the Tavistock & Portman NHS Trust from 1998 to 2018. Additionally, he played a pivotal role as one of the founding members of the Fitzjohn's Service, aimed at treating patients with severe and enduring mental health conditions and/or personality disorders. Throughout his career, he has extensively contributed to both writing and teaching. He is the author of three books: ‘Making room for madness in mental health: the psychoanalytic understanding of psychotic communications’, published by Karnac in 2016; ‘Psychoanalytic thinking in mental health settings’, which introduces frontline mental health professionals to psychoanalytic thinking and was published by Routledge in 2020 and his third book, co-written with his wife Susan Evans, titled ‘Gender dysphoria: a therapeutic model for working with children, adolescents, and young adults’, published by Phoenix in Evans & Evans, 2021. Address for correspondence: [
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