Contemporary Psychoanalysis in Action

A roundup of psychoanalytic points of view

A Man Walks into a Therapist’s Office and Says He’s a Woman

It’s hard for me to imagine how the therapist felt when my friend J, who lives as a married man with several young children in an ultra-Orthodox Jewish enclave in the U.K., showed up for her first appointment dressed, as we trans people say, as herself. Read More

This person clearly has more

This person clearly has more psychological issues than just thinking they are in the wrong body. If he wants to kill himself because he thinks he needs a vagina to be happy, what will he do when someone tells him God doesn't exist? People that truly have gender dysphoria have certainly been through difficulties, but those difficulties are sometimes causes of the issue more than symptoms. Additionally, calling someone that is - and will always be - a male "she" is simply ridiculous. Words have definitions, and changing them to make a very small portion of the population satisfied is a bad idea. If you are born with male genitalia, you are male by definition and cannot change that - even by having parts cut off and hormones changed and acting like what society tells you women act like.

Not that simple

Anonymous wrote:
If you are born with male genitalia, you are male by definition and cannot change that

Obviously you have no experience with Intersex people.

I know this is a specialised area, but your simplistic view is either based on biological ignorance, or political/religious ideology.

Just to give an example that might broaden your mind, leave you open to the suggestion that things are not always so simple - see these examples of 5 alpha reductase deficiency.

Some people are born with (mostly) female genitalia, and that masculinises later. 17BHSD and 5ARD are the most common causes, but there are others. Others are born with (mostly) male genitalia, but that feminises later. Again, a variety of causes.

Therapy can be useful in the majority of such cases. While rare in the USA, in other parts of the world these "natural sex changes" can comprise up to 2% of the population.

Gender change in 46,XY persons with 5alpha-reductase-2 deficiency and 17beta-hydroxysteroid dehydrogenase-3 deficiency. Cohen-Kettenis PT. Arch Sex Behav. 2005 Aug;34(4):399-410.

Trans women are born with mixed anatomy too.

See A sex difference in the human brain and its relation to transsexuality by Zhou et al Nature (1995) 378:68–70.

Our study is the first to show a female brain structure in genetically male transsexuals and supports the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones

I can't give you the complete lecture series on such issues - let's just say this is a specialised area, and inexperienced therapists who have simplistic notions and misconceptions about it are a menace.

Brain differences

The trans community will only advance if they acknowledge, as a community, that they were born with different brains on the Bipolar spectrum.

Public acceptance means personal acknowledgment,of the other true self.

You can't expect people to accept the truth when trans people only accept half of the truth.

A supporter.

What a brave and poignant

What a brave and poignant piece you have written here. Thanks for writing about a subject that pushes so many people's buttons. It is important to be brought out into the light, to be heard.

Dangerous ground

"There aren't many therapists who understand gender identity issues, and J's therapist, despite her missteps, sounds kind and well-meaning."

But hopelessly incompetent and inexperienced in this area. This is a case where you need an expert, an untrained amateur is likely to be worse than nothing. The patient needs a specialist who knows what they're doing, not someone who hasn't even read the literature.

If the therapist can get up to speed, if before the next session they've read up on the subject and seen just how badly they screwed up in the initial session, then yes, it can work. If they continue to see the situation through a prism of general therapy... the patient's life is seriously at risk.

I agree I mean does him

I agree I mean does him transitioning to her make him a worse parent often times kids are ok with things like this when they are younger and are only disgusted after they have been told it is disgusting. He should be himself is he a better parent dead

A quick guide for therapists in this situation

Only about 1 in 3000 of the general population has such issues. It's likely that a therapist will never see an example of Transsexuality (to use the ICD diagnosis) or Gender Dysphoria (DSM-5) in their careers. Intersex patients have their own issues too, especially those whose bodies were surgically altered when they were babies to look like the wrong sex.

If I can give some advice - recognise when you're out of your depth, and refer the patient to someone who knows this stuff. You can act as a filter for Florid Psychosis or other possible syndromes with only superficial similarities to these syndromes, but otherwise either do a lot of research on the subject, or pass the patient on to someone who knows what they're doing.

Two useful albeit over-simplified, papers which give you the basics. In fact, there are degrees, different parts if the brain can be affected, so there's no "one size fits all" therapeutic course. You must tread carefully, ~40% of such patients still alive have attempted suicide.

Sexual Hormones and the Brain: An Essential Alliance for Sexual Identity and Sexual Orientation Garcia-Falgueras A, Swaab DF Endocr Dev. 2010;17:22-35

The fetal brain develops during the intrauterine period in the male direction through a direct action of testosterone on the developing nerve cells, or in the female direction through the absence of this hormone surge. In this way, our gender identity (the conviction of belonging to the male or female gender) and sexual orientation are programmed or organized into our brain structures when we are still in the womb. However, since sexual differentiation of the genitals takes place in the first two months of pregnancy and sexual differentiation of the brain starts in the second half of pregnancy, these two processes can be influenced independently, which may result in extreme cases in trans-sexuality. This also means that in the event of ambiguous sex at birth, the degree of masculinization of the genitals may not reflect the degree of masculinization of the brain. There is no indication that social environment after birth has an effect on gender identity or sexual orientation.

Biased-Interaction Theory of Psychosexual Development: “How Does One Know if One is Male or Female?” M.Diamond Sex Roles (2006) 55:589–600

A theory of gender development is presented that incorporates early biological factors that organize predispositions in temperament and attitudes. With activation of these factors a person interacts in society and comes to identify as male or female. The predispositions establish preferences and aversions the growing child compares with those of others. All individuals compare themselves with others deciding who they are like (same) and with whom are they different. These experiences and interpretations can then be said to determine how one comes to identify as male or female, man or woman. In retrospect, one can say the person has a gendered brain since it is the brain that structures the individual’s basic personality; first with inherent tendencies then with interactions coming from experience.

That gives the basics within a simplified binary gender model. In fact, while the binary models for both sex and gender are good approximations, they don't fit everyone. This is obvious in the case of Intersex patients whose bodies are visibly different from both a male or female norm, but gender is even more fuzzy, and requires guided exploration of the individual's case by the patient, the therapist's role restricted to providing moral support, education, and pointing out options.

Caution Needed

A quick look at current research will show that the articles and research cited by the above have all been refuted by the academic community and just stand for political reasons. Unfortunately, to date no science supports the political position of "transgender" being a "birth defect" a female brain in a male body, nor does any research show that it is in anyway related to a single "intersexted" condition, which are biological conditions that can be verified by medical tests. What is known is that 80% of males claiming to really be women are heterosexual men with a long history of fetishistic cross-dressing. And many may suffer from "autogynephilia" the love of oneself as a women. As expected his is not a very well liked conclusion by transgender activists.

And here are people with a very similar "disphoria" that believe they need a limb amputated to be happy or they need to be paralyzed. It is a good thing that the DSMV is headed to the trash. Let’s remember, “Recovered memory syndrome” and “multiple personality disorder”

Debunked? Not as such...

Anonymous wrote:
A quick look at current research will show that the articles and research cited by the above have all been refuted by the academic community

A more detailed look would show it hasn't.

Regarding the URLs.

1) Is for a BIID political website - irrelevant, different diagnosis, and an opinion piece.

2) Is a blog entry, not passing peer-review for publication. Nonetheless, it's a good critique containing some well-considered objections, that have been answered by a number of papers. It does contain a number of unfortunate errors of fact, and completely misinterprets Pol et al's work. Many papers have shown that the areas in question are insensitive to post-natal hormones - though other areas are.

3) Is for a different diagnosis - transvestitic fetishism - irrelevant.

4) While interesting, is about a popular book that even the author of the article describes as "not a scientific work".

Re variance and invariance during HRT see for example:

White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study. - Rametti et al, J Psychiatr Res. 2010 Jun 8.

Regional cerebral blood flow changes in female to male gender identity disorder. - Tanaka et al, Psychiatry Clin Neurosci. 2010 Apr 1;64(2):157-61.

Biological and Psychosocial Correlates of Adult Gender‐Variant Identities: a Review by J.F.Veale & D.E.Clarke, Personality and Individual Differences (2009) 48(4), 357-366

Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structur by Pol et al, Europ Jnl Endocrinology, Vol 155, suppl_1, S107-S114 2006
(demonstrating change in structure size but contrary to Lawrence's assertion, not cell type distribution)

The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI study Rametti et al Journal of Psychiatric Research

Neuroimaging Differences in Spatial Cognition between Men and Male-to-Female Transsexuals Before and During Hormone Therapy by Scoening et al J Sex Med. 2009 Sep 14.

Regional gray matter variation in male-to-female transsexualism. by Luders et al Neuroimage. 2009 Jul 15;46(4):904-7.

...and so on and so on.

Professor Ecker's presentation to the APA 2009 annual conference on the issue is germane.

Gender Identity is that innate sense of who you are in this world with reference to your sexuality and behavior, not necessarily corresponding to your genitalia and reproductive organs. Transgenders are atypical and “think” as the opposite gender. Certain areas of the brain have been shown to be sexually dimorphic. They are different in structure and numbers of neurons in males versus females. Protein Receptors for the sex hormones in different areas of the brain (limbic and anterior hypothalamic) must be present in sufficient numbers to receive those powerful hormones. There are androgen receptors (AR), Estrogen Receptors (ER), and Progesterone receptors (PRs). ARs or ERs are predominant at different times in different parts of the human brain. Hormone receptor genes have been identified in humans, which are responsible for sexually dimorphic brain differentiation in the hypothalamus. The groundwork in brain gender identity is gene-directed and takes place by forming male and female hormone receptors in the brain before the gonads and hormones can influence them. Multiple genes acting in concert determine our sexual identity. The human brain continues to make neurons and synaptic neuronal connections throughout life. This contributes to Gender Role Behaviors making individuals in the continuum of gender identity. Gender behaviors must be differentiated from gender identity (Hines). Gender Identity cannot be predicted from anatomy (Reiner). Brain gender identity is determined very early in fetal development, but gender expression, expressed as behaviors requires hormonal, environmental, social and cultural interactions, which evolve with time. One cannot deny the profound effects of Testosterone, Estradiol and other steroids on genital differentiation in-utero or their effects on behavior from birth or the physical and mental cross gender changes caused by exogenous hormones, but gender identity is determined before and persists in spite of these effects.

A good basic primer on it is

Clinical Implications of the Organizational and Activational Effects of Hormones M.Diamond Hormones and Behavior 55 (2009) 621–632

The organization-activation theory posits that the nervous system of a developing fetus responds to prenatal androgens so that, at a postnatal time, it will determine how sexual behavior is manifest. How organization-activation was or was not considered among different groups and under which circumstances it is considered is basically understood from the research and comments of different investigators and clinicians. The preponderance of evidence seems to indicate that the theory of organization-activation for the development of sexual behavior is certain for non-human mammals and almost certain for humans.

You appear to be under the misapprehension that the research has been "debunked" as the views of a few politically-motivated authors, rather than it being the well-evidenced mainstream view held by neurologists, diagnostic imagers, endocrinologists, and biologists, as well as many (but by no means all) mental health professionals.

You are correct that the area has become politicised - but it's the critics, not the researchers, who do that. Some admit it. This is illustrated by the following interview with Dr Ray Blanchard, whose work is the foundation for Dr Lawrence's and Dr Bailey's publications :

Do you think autoandrophelia, where a woman is aroused by the thought of herself as a man, is a real paraphelia?

No, I proposed it simply in order not to be accused of sexism, because there are all these women who want to say, “women can rape too, women can be pedophiles too, women can be exhibitionists too.” It’s a perverse expression of feminism, and so, I thought, let me jump the gun on this. I don’t think the phenomenon even exists.

The very opposite of objective, evidenced-based research! They make stuff up.

Caution Needed

Mental health professionals will be reconfiguring the treatment. Future clinical management will be based on the conclusions of neuroscience and not sociocultural positions about gender. The client narrative approach-- client centered in which the client can obtain whatever therapeutic service they like will also change in light of the science. All this research contains the phrases “may suggest” and “of no statistical significance’. In other words proves nothing. They are called “theories” for a reason. They have not been proven. And these do not serve as any proof either—not by any academic standard.. What readers would benefit from observing is the nature of the post—I would doubt that this is a clinician posting or anyone doing funded peer reviewed research. The excessive nature suggests a co-morbid condition. Evidence of what clinicians have to deal with when treating these clients.

The nature of the pathology and the complexities are clear to a nuanced reader. As are the threats of suicide and what Lawrence calls Narcissistic Rage in Autogynephilic Transsexualism
Clinicians are getting ready in the next decade to deal with an onslaught of “detransition” and regret.


At the risk of feeding trolls...

Assuming that you're trying to get a valid point across,
1) Posting as "anonymous"
2) Making easily refuted assertions such as "research cited by the above have all been refuted by the academic community" and backing them up with irrelevancies and blog entries
3) Engaging in "ad hominem" attacks when extensive data is adduced in rebuttal

Don't do anything to help your argument.

It was necessary to rebut the idea that this extensive body of research was an outlier, the eccentric ideas of a few idealogues. Hence the short list of references, barely adequate for the job. If you think that's a long, even obsessive one, you haven't read many papers on the subject.

Argument by Authority is always suspect, but I've been called in by professors of Medicine and Psychology to teach on this issue at the Australian National University. That doesn't mean I'm necessarily correct; but it does allow those mental health professionals reading this to better judge the reliability of my words compared to those of an anonymous blogger.

Note though that Dr Lawrence's blog entry contained valid criticisms that needed answering. It's because I believe that you may have some good points to make that I'm asking you to make them, and give professional-quality evidence in support.

I really enjoyed this blog.

I really enjoyed this blog. There are so many people having this problem and aren't given the opportunity to even visit a therapist to attempt to understand what is going on with them. If the social world was more apt to accepting those with Gender Identity Disorders less people would feel so hopeless about this. Many don't understand what people are going through mentally and physically and this gave a very good insight. Thanks for the blog!

As a transsexual woman, I can

As a transsexual woman, I can say that I was aware of an issue with my gender well prior to puberty (as is the case with most of us diagnosed with GID). Had I not transitioned, I would have committed suicide. I had to give up my marriage, my relationship with my children, and be called "a defiler of the church" in front of my congregation. This condition is not a mistake, it is the normal human variation of gender which takes place among all of us to varying degrees. The GID is not due to our being different, it is due to society's reaction to us. Knowing that you will be considered "a freak, a pervert, etc" is enough to cause our angst. We need to be counseled by professionals familiar with gender issues. I did not transition for reasons of sexual satisfaction. I transitioned to be myself. If I can't be happy being me, I sure can't have healthy relationships with others.

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Contemporary Psychoanalysis in Action, edited by Susan Kolod, Ph.D., and Melissa Ritter, Ph.D, is under the auspices of Contemporary Psychoanalysis, the journal of the William Alanson White Institute.


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