Psychology, what the analyst makes of the mind, by necessity, must see toward the complex, above the ideologically convenient and beyond the simple. “Our psychology,” William James writes, “must therefore take account not only of the conditions antecedent to mental states, but of their resultant consequences as well.” Approaching the psyche, then, it is not only that which comes before that matters, all that has been, but that which comes after, one’s development onward—all that could be. On the relation between the mind and the body, the self in one’s state of being, this observation appears at the beginning of James’s 1890 work The Principles of Psychology.
A few years ago, I remember having read a headline in The Guardian that said “Governor of Tavistock Foundation Quits Over Damning Report into Gender Identity Clinic,” published in February of 2019, about Marcus Evans. Whether more or less conservative or liberal, many have seemed mistaken in the widespread belief that what can be called “gender dysphoria” names a medical problem with a medical solution. Applied to the concept of “gender identity,” which seems to be seen as another word for one’s sense of self, this basic idea of being sick followed by being cured has seemed lacking in critical attention. Alongside the Evanses, we will return, albeit in brief, to the self in society and the paradigm of pathology—or, as Thomas Szasz critiques of psychiatric diagnoses: a belief that diagnoses are diseases. We might wonder just what it means pertaining to gender dysphoria, a state of mind in the body, and, more to the point, the great problems that have been produced by this conceptualization.
Thinking back to that 2019 piece, a passage from Marcus Evans’s resignation email to the Tavistock, as quoted by The Guardian, seems to remain of significance. Evans writes:
I do not believe we understand what is going on in this complex area and the need to adopt an attitude which examines things from different points of view is essential. This is difficult in the current environment as the debate and discussion required is continually being closed down or effectively described as ‘transphobic’ or in some way prejudicial.
Then, just months later, in October 2019, another piece appeared, this time published in The Times, with a headline that said “Therapist Raised Alert at Troubling Practices at Tavistock Clinic,” about Susan Evans. As before, the following observation seems important still, especially in the aftermath of the Keira Bell case. Evans writes:
When you work in the area of gender dysphoria you begin to see that many of these children have other areas of concern or difficulty, such as depression, autism, trauma, childhood abuse, internalized homophobia, relationship difficulties, social isolation and so on.
Between the Evanses’ accounts, which seemed rather similar to what I had been hearing from other mental health professionals, albeit in whispers, there have been similar concerns about the pervasive medicalization of gender. Broadly having been suppressed, these concerns have particularly regarded medicalizing children and young people, but they can apply, more generally, to such practices becoming more harmful than helpful, even for adults. By 2019, my own concerns over queerly unacknowledged and unaddressed misogyny and homophobia, in both law and medicine, had only been continuing to increase. Then, I read an essay by Julia Diana Robertson about Jaah Kelly, R. Kelly’s daughter, and how the medicalization of gender has an impact upon otherwise gay youth.
In her case, at only fourteen, Jaah believed that she must truly be male for two main reasons: her not being feminine and her being sexually oriented toward other members of her same sex. “I knew that I was a girl who liked other girls,” Jaah tells us, adding: “But because of what I was taught, I felt like the only way you could like another girl is if you were a boy.” By eighteen, however, she realized that her thinking she must not be female, in her case, seemed to come mainly from internalized homophobia. This case might well be compared with the more recent case of Keira Bell, who, unlike Jaah, had already been medicalized—going too far along with it by then.
To me, at the time, it seemed very striking that Jaah’s case appeared similar to those of so many other females around her age, those who believed they must be male. Among patients, degrees of distress arise in relation to the developing female body, typically with relation to having breasts and, in particular, experiencing menstruation. Diagnosed as “gender dysphoria,” this bodily discomfort has seemed to be something appearing, in recent years, far more so for girls than for boys. Between the sexes, the social conditions around gender identity development also seem to be significantly different, but often unremarked as being so. A “one size fits all” assumption in treatment, which can be the case, might indicate this failure for sexual difference to be drawn out. More remarkably, there has been a change in the patients who present at gender identity clinics. In the decades before, seen in all existing studies on this subject, most cases of childhood gender dysphoria had involved male children, not teenage females.
Over the past few years, I have been observing an odd increase, an unprecedented spike, in teenage females, a disproportionate number of whom have autism, presenting at gender identity clinics. They say how they should be male, not female—and therefore also must be medicalized to make it so. A newer paradigm of “affirming” them as “transgender,” taking each young patient here to be a boy trapped in a girl’s body, does not question what underlying problems might be there. Diving into the wreck, as others have done, I have seen deep issues that, despite any fear we might feel, require our reflection. In all of the talk about doing more research, there has been dread toward doing precisely that, primarily because ideology has come into conflict with reality. Following the Evanses and Robertson, among the few writing such analyses, I then finally joined those who have been standing on trial.
Written by Susan Evans and Marcus Evans, Gender Dysphoria has been a critical addition to the continued analysis of our psyches and ourselves, significant in the present debates around the medicalization of gender. Discussions of gender dysphoria have been polarized by political activism, seeming to be dead ends, where one falls into empty rhetoric about “affirmation” and “conversion.” But the Evanses, as they tell us, make a point in their model of being “neither ‘pro’ nor ‘anti’ transition,” departing from the unhelpful dualistic framework. Engaging this subject with true nuance, then, the Evanses’ proposed therapeutic model considers the individual, specifically the drives and the motivations submerged beneath the surface. Of some concern here, contemporary approaches, most notably the “gender-affirming” model, have not been this way, lacking this understanding: one size does not fit all. A lack of consideration for drives and motivations for the individual could very well be dangerous and deadly. It can be especially costly in the case of misunderstanding other underlying mental health conditions.
Above, in my sketch of Jaah Kelly, we see elements, here and there, which the Evanses explore in their book. They argue that, for the child or young person with internalized homophobia, adults being “affirming” of gender identity, such as in cases like that of Jaah, can be their collusion in homophobia. In such a case, “affirmation” would serve not to actualize, but rather to alienate the individual from coming to terms with having a homosexual orientation. The defense mechanism expresses itself in denial, here a basic fear of being gay, where continued repression takes the place of resolution. “Affirmation” poses a problem, not because it considers the changes in individual development, but rather because it actually denies the dynamic nature that needs attention in the development of the self. A contradiction, “gender fluidity,” all of this rhetoric about rebelling against “the gender binary,” corresponds to a rigid framework of “gender identity”: to make real “the ideal self,” it must be medicalized into being. “Self-actualization,” in this sense, can become revealed as self-annihilation, with the patient not closer, but rather so much farther away from the true self. What I depict here for the reader is but “a certain Slant of light,” to draw from Emily Dickinson.
Pain can be characteristic of one’s bodily feelings—at least, it does seem to be so, in one way or another, during the life course. Psychic pain happens not only with relation to the body but also within the body. By contrast, one might imagine a painless existence, where the self can become safe from all stress, either real or imagined in nature. But the patient should not be led to expect that promise from the professional. “Psychoanalysis,” the Evanses write, “has a basic assumption that being involved in life is a painful business and that it helps if the individual can be supported in bearing pain, rather than attempting to eradicate it.” As the Evanses write, it can be far more harmful, rather than helpful, for the patient to believe in a false premise of the eradication of all pain. Indeed, as the authors explain it, the false idea of taking away all pain not only plays into paternalistic attitudes toward the patients but also presents false promises. For children, the idea that any psychic pain, including gender dysphoria, must be deadened by medicalization can be extremely damaging to their development. The Evanses write:
Children need to develop a capacity to notice pain and be helped to understand and process the experience as part of their learning about themselves. Children also need help differentiating the type, degree, and cause of pain and to be given some confidence that psychic pain can be both tolerated and understood.
There would seem to be, then, significance in learning that not all pain must be intolerable for us, as if utterly beyond our understanding, and that deeper issues can drive us to fear even feeling itself. On trauma, one might consider Bessel van der Kolk’s 2014 work The Body Keeps the Score. Indeed, the point of psychoanalysis, as the Evanses apply it, seems to be the support of the individual as part of one’s developing sense of self, thinking about one’s interiority with relation to others in the external world. However, a contrary assumption within the wider culture has seemed to involve the patient going to the clinic and the professional then giving a cure to a disease. Following this framework, particularly applying it to the making of mental illness, one might be led to believe, rather simplistically, that a medical problem should be met by a medical solution.
Cases discussed by the Evanses give the reader a view into the complexity of each individual patient, something far beyond the space of this review. In reading the book and writing notes, I find myself considering each patient and really wanting to return to think further into this or that set of social conditions affecting the individual psyche. Those involving teenage girls remind me of the work of the German-American psychoanalyst Hilde Bruch, particularly her 1978 book The Golden Cage, in which she discusses anorexia nervosa. Regarding the girls, the Evanses’ observations hold similarities to those observed in Bruch’s work, including fears of adulthood, hatred of the female body, and the making of identity as a method of control. In Bruch’s cases, there were also similar troubles between the girls and their families, struggles over control typical in adolescent development. But, in such cases, the identities were not being cemented into place by social institutions and their potentially harmful, even if well-meaning, interventions.
How does one become who one is—or, more precisely, who one will be? There seems to be a concept of “killing” “the false self,” for it to “die,” thereby allowing the “birth” of “the true self.” The religiosity of this idea of identity really betrays itself. But, even more than the bizarreness of “gender identity” becoming a secular religion, this paradigm can pose any number of problems, ones that the Evanses book indeed brings into the light. In his 1984 work Narcissism, Alexander Lowen, a student of Wilhelm Reich, writes of the meaning of “specialness,” this sense that one actually must be above others. Meaning for the self, whatever one might seem to perceive as such, becomes itself bound to the subjugation of the other. The one subjects the other to one’s “specialness.” There seems to be some application here to what the Evanses discuss of “the ideal self” among patients for whom the fantasy becomes a fixation. “Through the new self-image,” Lowen writes, “they compensate for the sense of unlovableness and unworthiness that they previously experienced.” This concept of “the authentic self,” however, could be exposed as the false perception of authenticity, only further artifice in the denialism of true selfhood—all that could be.
Reading Gender Dysphoria, I find myself reflecting on another work, old and yet oddly fitting, particularly for the present subject: The Neurotic Personality of Our Time, a 1937 work by Karen Horney. In her book, Horney defines the term “neurosis” as “a psychic disturbance brought about by fears and defenses against these fears, and by attempts to find compromise solutions for conflicting tendencies.” The analyst sees in this psychic disturbance called “gender dysphoria” a comparable set of symptoms, similar anxieties and defenses analyzed in the literature, dating back decades. As seen with Bruch and those with anorexia nervosa, with their corresponding multidisciplinary treatments, one cannot help but draw comparisons between then and now. More chillingly, one might also contrast the protocols and treatments from then with those now said to be “affirming” and sold as “life-saving.”
Thoroughness, both the before and the after, together, matter in the analysis of the patient. One might say that, with regard to the mind, the pill and the procedure alike have been historical methods for dealing with matters of the mind. Can the patient be promised something that might not come true? “The fantasy that the body can be changed and sculpted as a way of being rid of profound psychological problems,” the Evanses write, “needs to come under much closer scrutiny.” Capitalistic and consumeristic, buying a “new” body, either to escape from development and one’s corresponding distress or to distract oneself from other pain, must be critiqued. Perhaps more consumeristic than previous eras, political activism has made a model for gender medicine now defined by the dictum “the customer is always right.” Following this point of view, in a 2018 op-ed for The New York Times, transgender theorist Andrea Long Chu writes how “surgery’s only prerequisite should be a simple demonstration of want.”
In these neurotic times, engaging us with their analyses, the Evanses give the reader a look into this one fashion of the mind in its feeling. Finding the body as the self left to medicalization, more so now than before, has become the more frequent lot for those who see themselves as somehow not their sex on the basis of gender identity. An understanding of a condition followed by a cure, one’s destiny in one’s diagnosis, has been the rationale for the medicalization of gender. This basic dynamic has become maybe the most evident for children and young people.
Being at once compassionate and still critical can be an insurmountable barrier, as most writers know all too well, but the Evanses brilliantly do just that in this book. Although itself complex, like all matters of the mind, psychoanalysis applied to the self in relation to sexual being appears presented in a comprehensible way for the common reader. To the Evanses, I express my thankfulness for their work.