Gender
Dysphoria

This chapter offers an introduction to the developmental approach described throughout Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults.

Although it focuses on adolescence and gender distress, its central ideas are relevant to all parents, teachers and clinicians seeking to understand how identity develops and how young people can be helped to think about themselves during periods of confusion and change.

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Chapter 6. Adolescence, Identity and the Developing Self

Every adolescent has to answer a series of profound questions:

• Who am I?
• What sort of adult will I become?
• How do I separate from my parents while remaining connected to them?
• How do I come to inhabit my changing body?

In Chapters 4 & 5 we considered how parental relationships early in life shape the infant's capacity to withstand uncertainty as they pass early developmental milestones. Here we are concerned with the transition from childhood to adulthood, which involves huge physiological, psychological, and sociological changes. Although we typically associate adolescence with the teenage years, neuroscientists understand adolescence to be a process that is not usually completed until an individual reaches their mid-20s, well into legal adulthood.

Meanwhile, in the body, sex hormones kick-start the development of secondary sexual characteristics (see pp.). This change in the body is usually accompanied by profound changes in relationships with parents and the outside world. The trajectory towards adulthood presents all sorts of demands and questions to the emerging adolescent: what sort of adult are they going to be? How will they separate from the influence of their parents? How will they manage sexual relations in the adult world? These questions may not be in the foreground of the young person's mind, but they exist in the background of everyone's mind. All these shifting demands create both excitement but also anxiety about what the future holds.

Separation and rebellion

For some adolescents, the process of separation produces fights over independent status as they challenge the adults in positions of authority who oversee their lives. The battles between young person and parent are often fought over the rights of the adolescent to control their decisions and their right to treat their body as their own.

Arguments therefore rage over skin piercings, tattoos, hair dyes, fashion choices, how late they stay out, the company they keep, their attitude to schoolwork, sexual behaviour, appropriate dress, experimenting with drink and drugs, or changing their appearance in more dramatic ways. Adolescents often live in a world where the difference between fantasy and reality has not been fully established. Although the rebellious adolescent may fight for independence, they can be distraught and break down in tears when the implications of their reckless behaviour become evident. “Leave me alone! It's my life!” can rapidly turn into, “My life is over! I’ve ruined everything.” Parents are often aware of the dangers this period holds, as rebellious activity may result in unwanted pregnancy, drug overdoses, or fights in which an adolescent is injured, or worse, dies. The adolescent brain has a skewed notion of risk assessment in comparison to the adult brain, especially in the company of peers. Thus, they might cross a road recklessly as if they were immortal or drive under the influence of alcohol without realising the dangers. It is a period characterised by the teenager acting like a grown-up who can make his own decisions, but who needs the parents to pick up the pieces if or when things go wrong.

The importance of peer groups

Peer groups in adolescence usually become much more prominent and important as the group represents a place where the adolescent can share the journey with other kids. In the group, there is often a range of attitudes with different presentations. For example, the kids that are experimenting with sex, talk within the group, while others listen in to the details. The sheepish one hides in the group ashamed of their lack of physical maturity but gets on by being funny or cheeky. The peer group provides a place where the adolescent can experiment with different ways of being. There are leaders of the group who dominate and followers who may appear to tag along for the ride. While they may wear clothes or behave in ways that exist outside their parents' social norms, the groups often have a definite ‘on trend’ uniform. These uniforms are the outward expression of the groups underlying values and ideologies. These adolescent groups can be underpinned by bonds of loyalty and belonging, offering an alternative to their family of origin. This is part of a normal process of separating from the parents and the family and finding an individual identity.

Fear of adulthood

Some adolescents, perhaps terrified of the adult world, cling to an infantile attachment to their parents as if they are still little children who could not possibly make any decisions of their own. They might not join a peer group fearing that they are not ready for the separation from their parents. Parents may be faced with the opposite problem to the reckless tearaways, as the teenager needs cajoling into adulthood. They may be anxious about their sexuality and the demands of adulthood, hiding behind their parents' views and sticking closely to the family or locking themselves away in their bedrooms. More formal groups, like school trips, or clubs, can provide a halfway house where the young person can separate from the parents, while the group is organised by teachers or adults who act in loco parentis.

Adolescent development

For most adolescents, they are both fighting to establish their own identity by rebelling against their parents, but also in some way struggling to incorporate their parents’ ideals. The projections and projective processes underlying this process are unconscious - the young person is usually unaware they are doing this - but these projections can have a disturbing effect on others. The boy who argues with his parents, stating that he does not care about his upcoming exams, projects his anxiety about his future into his parents, who are left carrying the worries.

The adolescent is also usually extremely self-conscious and is compelled to compare himself against others. The world of social media has increased this tendency as Facebook, Instagram, Tik tok and similar, exploit teenagers’ strong urges to find out how popular they are, how handsome, or how funny. Facebook began, after all, as a method to compare the desirability of girls on the campus at Harvard University. ‘Likes’ on certain accounts have been scientifically shown to alter brain chemistry by stimulating the brain’s reward circuits and promoting the release of endorphins.

The focus on the external environment is often driven by the wish to manage internal anxieties. The adolescent may fall back on primitive, defensive states of mind to manage their internal states, which is why teenagers are notoriously moody and changeable. They project a lot into the external world in order to master their unruly feelings. These projections can sometimes be accompanied by actions designed to provoke a response in others. In this way, an internal conflict is now acted out in the external world. So, for example, the girl who goes out with older men is dismissive of her mother’s concerns about whether she will be hurt or led astray.

The adolescents’ sense of themselves is extremely volatile as they can quickly be overwhelmed by anxieties, so their functioning fluctuates between being grown-up and integrated on the one hand and feeling very infantile where the world is too much and wholly against them. Parents sometimes struggle in managing the provocation, while trying to understand the underlying conflicts, as their child may present them with reminders of their own conflicts and struggles in their childhoods. The professional working with adolescents has to be prepared for the dramatic changes in mood a patient can present with. The work requires patience and resilience in the face of sometimes overwhelming or frightening provocation.

The transition from childhood to adulthood is a crucial threshold moment in the development of the individual, throwing up all sorts of psychic conflicts confusions and challenges.

Disdain towards authority

Rebelliousness against parents can be represented in the adolescent choice of political affiliation, disdain for the older generation and authority. It is an important stage in de-idealising the parents and a way of saying, “You lot do not know what you are doing. When the new generation are in charge, then we will create a better world”.

Meanwhile, drugs and alcohol are often used to deal with anxiety by changing the brain state to escape from underlying feelings of persecution or confusion.

Powerful defences

The immature ego deals with anxiety by projecting any persecutory thoughts, threatening, internal desires and psychic conflicts into the external world. It also often splits the world into all-good and all-bad states.

A 15-year-old boy who has recently had to re-sit his exams goes into a rage at his father’s incompetence at texting. Thus, feelings of humiliation are projected into the father. The son is left feeling completely in control and in charge, while his father has been identified as the stupid one.

Conversely, a 14-year old girl, who lacks confidence and fears responsibility and separation, continually asks her mother to do things that she is fully capable of doing herself. In this way, she plays the role of an anxious infant that depends on her mother totally, by projecting her capabilities into her mother. There is an avoidance of the reality that she is becoming an adult who should be expected to take responsibility for her actions.

In both these examples, an internal conflict has been projected and acted out in relation to another. Parents can struggle to see clearly that these interactions are driven by unconscious projective processes designed to provoke strong emotional responses in the recipient.

Exploration of gender: a normal part of development

Childhood and adolescence are developmental processes, and all individuals experiment with different identifications, both male and female. This can stir up all sorts of confusions, doubts and conflicts which drive the individuals to employ powerful psychic defences such as denial, splitting and projection. When these forces become overwhelming, they may push the individual to focus on a fixed solution in an attempt to reduce feelings of confusion - one of which might be, "I’m not the sex I was born, I am the other gender." " In adolescence, the experience of being dislocated from one's body, which is changing rapidly, is common. It is these experiences that will secure the link between mind and body in the mental life of the adult to come. In many ways, adolescence involves making your body your home and ‘moving in’.

When considering the more recent trend of ‘ROGD’ teenagers, (i.e. Recent Onset Gender Dysphoria, rather than the more traditionally reported group of younger children), there are several factors worth investigation. The general thinking behind the ‘ROGD’ cohort is that they are children who expressed no earlier ideas about their gender confusion, hence ‘recent onset’. A sudden presentation might have multiple and connected origin. Young children fantasise about many identities (e.g. dinosaur, princess, popstar, footballer, etc.), which may involve being another gender in their imagination. Children also often play in mixed sports teams and boys and girls can easily pass or be mistaken for a child of the opposite sex. Some children may harbour a conviction that they are of the other gender and this particular belief is easier to maintain for the young child, due to the more minimal differences in physical appearance and abilities, with the absence of secondary sexual characteristics (see pp.). There is also a societal acceptance of children displaying more gender non-conformity, for example tomboy girls or ‘girly-boys’.

In younger children these fantasies are more commonly transitory and fluid, whereas some children develop a more fixed belief system in connection with how they view themselves. However, as the child moves into puberty, under the influence of a surge of sex hormones, the body develops secondary sexual characteristics. At this point the contradictory ideas and beliefs the child had are more difficult to maintain and the young person is faced with the consequences of these changes to their body and its implications for their biological sexual role. The little girl who enjoyed life and was accepted as a tomboy may find her female identity more apparent as her body develops in adolescence. We could therefore regard ROGD as a response to the trauma of the reality of puberty, together with the loss of the freedoms of childhood identity.

In the medical treatment of gender dysphoria, the puberty blockers are used to stop normal physical development, thus putting a blanket over the young person’s sexual development. This may reduce their anxiety in the short term – hence the alleged improvement in mental state. The difficulty of administering early treatment of blocker hormones to children, is that the influence of the natal sex hormones on the body and mind during adolescence is interrupted. The influence of natural sex hormones on the body are clear to see, but they also have key roles in brain development and maturation and are likely to be the crucial components which influence the behaviours and emotions of young people.

Fantasies of adolescence

The adolescent may have all sorts of phantasies about the ideal self they would like to be in order to deal with the difficulties and demands associated with the adult world. They may feel persecuted by their failings and fall into morose states when faced with limitations or deficiencies. They may develop grievances towards their parents who have failed to give them the ideal body or mind or temperament they feel they need to succeed in the adult world. This can lead to arguments and conflicts where the adolescent blames the adult for their shortcomings.

Hatred of the sexed body

The adolescent’s anxiety can lead to feelings of dissociation as they locate irritation at imperfections or desires into the body, while distancing themselves mentally from these experiences. This can lead to an increase in the fantasy of, "If only I'd been given the ideal body/mind then everything would be OK" or, “If only I could return to being a young person, then I could escape from all these adult responsibilities”. This state can lead to a feeling that the body is no longer loved or wanted but is treated as if it was responsible for the failing of the self. Hatred of the body may become so great that the adolescent feels that their body is a separate entity and no longer anything to do with them.

The developing sexual characteristics increase anxiety and are treated like an unwanted visitor. Eventually, the adolescent can feel that their body is an alien thing or that they are a prisoner in a body they no longer identify with. At this point, the young person’s body now contains all the emotional persecutions and insecurities. The young person’s questions about their future sexual roles in adult life are then postponed, as they have become utterly preoccupied by the idea that they have been “born in the wrong body”. The trans-affirmative script goes something like this: “You feel at odds with yourself. You lack confidence and suffer from social anxiety. This is because you have felt you been born into the wrong body – you might be trans”.

Our minds naturally like to protect us against psychic pain and unconsciously we try to find less painful, arduous routes to psychic resolutions. The ‘trans-identifying’ adolescent starts to become more fixed in their belief that this is the answer to many of their problems. If only they could transition the distress would resolve and everything would be all right. When a fragile ego is under pressure, it tends to focus on the idea of one problem with one solution, as the individual fixes on a very narrow field of mental life.

A very similar process is evident in the anorexic’s fixed preoccupation with their weight, or in the obsessional compulsive’s preoccupation with cleanliness.

Control of the identity by enactment

The fixed belief about being trans can give the adolescent a powerful feeling of control as they believe that they can design their own perfect body. For many, transitioning also involves changing their given name. Thus, they have revenge upon their parents by rejecting the name they have been given as infant. The developing adolescent feels exposed to painful and humiliating aspects of life and may feel deep grievance towards the parents for being made to feel this way. In many ways, this is an omnipotent mental state as the young person develops a fantasy that he/she can re-create themselves and dispose of their unwanted identity.

Dagny (2019), a detransitioner, has recently published an article about her experience of transitioning. She highlighted the influence of the online site Tumblr and described the ways she internalised the ideals of the website.

One of these unhealthy beliefs I held was the belief that if you have gender dysphoria, you must transition. And anyone that appeared to stand in my way was a transphobe — an alt-right bigot. If I, myself, questioned my actions, I was suffering from internalised transphobia. No matter how much genuine concern others may have had for me — by now, a miserable 16-year-old — they were committing an unforgivable act if they just asked me, "Why"? Why do I want to be a boy? Why do I want to change my body?

The development of gender dysphoria or a ‘trans-identification’ appears to be based on a split between the individual's natal sex, which is disowned and rejected, and the attractive fantasy of a newly created identity which can usher in the age of a fantasised ideal self. The fantasy that the individual can sculpt the body according to his/her wishes adds to the feeling of power and control over the body and everything contained within it. The now self-diagnosed ‘trans person’ can put enormous pressure on family, schools and clinical services to join unquestioningly with them in the belief that transition is the only solution to their problems.

Splitting in the family

Eva was a 15-year old girl referred by her family doctor to a child and adolescent mental health service after saying that she wanted to transition. Initially, the team saw the family together, and it was evident that the parents were split over their daughter’s wish to transition. At the first meeting Eva’s mother asked the family therapist whether she thought they should go along with Eva's wishes to use a boy's name in place of her given name. The father added that he did not think that there was a problem with it and said that he wanted his daughter to be happy; the mother replied that she wanted to understand why Eva was not happy with who she was. The therapist asked Eva what she thought about her birth name and what she thought would change with the new name. Eva talked in a matter of fact way, about a feeling that she had never really liked her name and couldn’t think of herself as an Eva. The therapist said that it would be helpful to try and understand more about Eva and her family as well as the ideas behind her wish to change her identity. The family therapist agreed to meet the family once a term.

Eva started in once-weekly psychotherapy which ran alongside termly meetings with the family. Eva was one of non-identical twin girls, with an older brother and a younger sister. When she arrived in the consulting room, she smiled in a shy, pensive way that gave very little away about her underlying feelings. The therapist felt as if Eva was polite on the outside as a way of keeping the therapist from what was going on inside. The therapist asked Eva about her family. She said that her older brother, now 20, had been very depressed and suicidal as a teenager. The brother’s condition had dominated family life for a number of years as the parents always had to deal with his rages and tantrums.

While she said all this, there was a very little expression in her voice or face. The therapist commented that it sounded like the brother's illness took up quite a bit of the family's time. Eva shrugged her shoulders in uncommitted agreement. The therapist asked her about her twin and younger sister. She said that her twin was very bright, and her younger sister was very pretty and popular. The therapist tried to explore with Eva how she felt about herself in the family with her cleverer twin and prettier younger sister. Eva smiled and shrugged her shoulders but said that she didn’t really think anything about it. This tended to be the pattern of exchanges between them for several months, as if Eva had no intention of exploring her emotions and thoughts.

The therapist became aware she was doing most of the work in the session, in taking various imaginative leaps in response to how the patient seemed to be keeping them both in the dark.

After several weeks of therapy, the therapist said that perhaps Eva’s reliance on the therapist to do all the thinking and talking in the session, was like her somewhat hidden position in the family. This produced a small smile and another comment about having no thoughts on what the therapist had just said. However, this did seem to allow a subtle change in Eva’s appointment as she started to be more talkative about her outside life at school and her sports team.

Then in one session shortly afterwards Eva told the therapist that her mother did not want her to change her name or her school and that was why she wanted Eva to attend the therapy. This was said with tiny hint of irritation. The therapist said that maybe Eva felt annoyed that her brother had received so much attention from the parents, while she gets sent to therapist. However, Eva responded to this by denying any feelings of annoyance.

At the beginning of the next session, Eva looked at the therapist and asked what she should talk about. The therapist said she was free to say anything and that the therapist was interested in whatever was on her mind. Again, she smiled politely while falling silent. She then talked about an incident in which she remembered her oldest brother had screamed and shouted at her mother until the mother cried and Eva hated seeing any of this. Eva went on to say that the atmosphere was terrible as everyone was walking around on eggshells. The therapist commented that it must be difficult for Eva to express any irritation or anger herself, when the atmosphere felt so tense, and asked what she did when she got frustrated. She replied that she went to her room and contacted people on the internet in order to play online games or she would put her headphones on and listen to loud music so she couldn’t hear if anything more was happening downstairs.

The therapist said it sounded as if Eva was afraid to talk to her parents about any of the thoughts and feelings she was having, and it seemed as though her question to the therapist at the beginning conveyed, she also felt that way about her sessions. The therapist wondered with Eva if she was keeping others happy, rather than having any real expectation that she could get anything out of it for herself. She smiled more warmly at this, as if the therapist had rumbled this polite way of keeping herself at a distance, and therefore hidden. Eva then remembered that the therapist had said when they first met that she talks about an early memory she had and she mentioned that once she had been left in the car by the family. She said she was too tired to go on the walk, but they had got lost and were gone for hours. The therapist asked how she had been in their absence. Eva said that knew she had to distract herself and she kept telling herself the same nursery rhyme repeatedly. When they returned, she said nothing to them about feeling afraid or angry at being left alone for so long and the incident was soon forgotten.

The therapist commented on her need to soothe herself as if she had to manage all her distressed feelings on her own. She can never feel frightened or anxious or neglected. Eva looked challengingly at the therapist and said, "What's the point of feeling that way?" The therapist said that perhaps Eva did not expect anybody to be interested in her feelings or that it was worth the risk for her to shed light on what was going on deep inside her. She replied, “Feelings just cause pain; I cannot see the point in them.” Eva then retreated into a sullen state, repeating that she had no expectations of the therapy. The therapist also talked with Eva about how she imagined that Eva had probably felt scared and upset in the car but had managed her emotions by distracting herself with the repetitive rhymes. Even when the parents returned, she did not feel able to cry or complain.

During the following months of therapy Eva continued in this somewhat detached state of mind, causing the therapist to feel a mixture of either shut out or frustrated, but there were occasions when Eva became more engaged. The therapist learned that Eva was sensitive about how she was viewed by others and how she tried to fit in with the girls at school. She did not feel like she was one of the prettiest or the most intelligent. She was able to allow the therapist to explore and notice her sensitive and vulnerable feelings. However, there was a pattern which developed whereby progress in the therapy would be followed by Eva becoming suspicious of the therapy and pulling back from emotional contact.

Eva would shut down and then go back to saying that she just wanted to change her name and move to a different school. It was as if this issue was used to disconnect from any other emotions/feelings and to flatten any discussion about her as a person. Indeed, the therapist developed a belief that part of the fantasy of her transition for Eva was that she would get rid of this sensitive girl who left her exposed to feelings of vulnerability and a sense she couldn’t measure up. During these periods of the therapy, Eva sometimes talked about her mother's attempts to engage her in discussions about life or how she was getting on. She described going along with her mother, placating her, while inside she said she did not feel moved at all.

A few months into the treatment, Eva told the therapist that the class had been shown a film about child slave labour where they were exploited and treated badly by merciless bosses. Most of the class had been very upset and cried during the film. However, Eva said she was unaffected and did not get upset. However, she did comment on how different she was. The therapist said perhaps she identified more with the cruel bosses who neglected these young people and mistreated them in a sweatshop factory. This seemed to hit home with Eva because she looked uncomfortable and the therapist observed this.

Eva said, ‘Mmmm … but I do not like to think of myself as being so cruel.” Then, with a flash of anger, she said, “I just can’t see the point or what you want from me - you just want me to cry or be sad.” The therapist wondered whether Eva thought the therapy was a form of exploitation as now the therapist was like the factory boss who was just trying to make Eva feel dependent and needy. “Yes,” said Eva, “You just want me to feel unhappy or guilty, and I don’t see the point of all those feelings. Where does that get you?" The therapist replied that by ignoring her own needs, she was also cold and cruel to the part of her that wanted warmth.

Over the next few months Eva would sometimes be more open about her underlying hostility, occasionally pointing out the therapist’s deficits or mistakes. This was interspersed with moments of more humour or warmth.

Six months into the therapy, Eva came into the session complaining that the man who had come before her had left a terrible smell in the waiting room and that the therapist should do something about it. The therapist said it might feel to Eva just like her mother at home who lets her brother dominate the household with his outbursts. She said with real anger that her father did not do anything to help when her brother went into one: "He just stands by and watches." The therapist went on to say that perhaps Eva also felt her therapist was useless to her when she was silent about her difficulties, leaving her on her own without any support, just as she had been left in the car on her own. Eva did not reply but she sighed, her shoulders slumped, and she looked away at the bookcase as if trying to control her emotions.

A few weeks later, Eva was telling the therapist about how her week had gone. She mentioned that her father was a keen sportsman and used to take Eva to tag rugby when she was very small. Her twin sister did not want to go, and her other siblings were not that interested. The team had been mixed sexes until nine years of age when physical contact started. Eva’s father enjoyed the fact that she was so sporty and that she was a match for the boys. When she was about eight years old, she remembered him saying what a relief it was that he had somebody interested in sport, because the brother had not been. She said he was disappointed that her brother took no interest in sport. The therapist said Eva’s father’s comment about wanting a sporty boy seemed to have made quite an impression. Eva seemed pleased that her father and she had something in common and it made him happy.

A year into the therapy, Eva arrived in the session in obvious pain. Eva mentioned nothing and after a short time, the therapist enquired about her injuries. She said she had been hurt in a rugby match but had not wanted to go to the casualty department as she didn't want to have to wait to be seen. The therapist commented on the way Eva wished to ignore the pain her body was in, as if it was nothing to do with her. Eva replied by saying that the pain was only in her body and that she was almost sure she had not broken anything. Her only concern was that she could be fit in time for the cup match in two weeks’ time otherwise her coach would be angry.

The therapist thought Eva located all pain and desire in her body, which she then disowned. Eva then seemed to live with her mind cut off from her body. Instead of feeling the pain of a little girl who wanted her Mummy to take notice of the fact that she was hurting, she felt she could get rid of this part of her mind by transitioning into being a man. Eva said that girls are always crying and over-emotional, always hurt, but she wasn’t like that.

During the next months of therapy, Eva and the therapist were able to explore the way Eva had developed a belief that she would acceptable if only she could get rid of her grievances, desires and pain located in this little girl that she believed was unacceptable. The man she thought she would be was someone who would get on with life, and had no need of love or passionate relationships. This was repeated in the therapy, as Eva tried to control the distance and contact between her and the therapist, in an attempt to manage any intense feelings that threatened to emerge during the sessions.

In the second year of therapy Eva became more able to express her emotions and talk about different aspects of her life. She also reported that her relationship with her twin sister and mother had improved. She became a bit more critical of her father and his tendency to stay out of family arguments.

Two years into the therapy, with a small grin, Eva told the therapist that she had been asked out by, a guy at the local rugby club. She had turned him down “Because I’m not sure I’m into men, but it felt nice to be asked”.

In the third year of treatment, Eva started to talk about how she no longer thought she fitted into the categories described on the trans affirmative websites and rarely talked about her ideas of transition. Eva said that she had realised that the websites were not real life and no longer held any interest for her. The therapist said she thought Eva had realised that she was allowed to feel different things and express herself in different ways. She no longer had to be silent herself when she felt angry or loving feelings. There was also talk about Eva’s application to university. Eva said she felt worried about how it would go, that university was a big step, but she wanted to believe she would manage. She was reluctant to leave her current small friendship group and start again. The therapist began to talk more about the end of the therapy and next steps for Eva. They agreed the therapy would end that summer.

At the next session, Eva suddenly announced that she wanted to change her name, her father happy about it and it was only her mother who was being difficult. The therapist was taken aback by this announcement as this subject had not been an issue in recent months but started to try and look with Eva at what had brought about this idea. Eva seemed much more wary and unwilling to explore her thinking in this session.

The therapist drew attention to the fact that they had agreed an ending date at the last session. She said she wondered if the ‘little girl her’ felt upset about the loss of the therapy and now perhaps Eva wanted to distance herself from these feelings. Eva said in a dismissive way that it had nothing to do with the ending of the therapy and that she was fine with stopping.

After a long pause Eva said that her brother had had one his outbursts during the week and her mother had been trying to calm him down. The therapist said that Eva might be feeling she would be replaced by the patient who used to leave smells in the waiting room, as her brother had taken her mother’s attention. Eva replied, “It is what it is - I’m used to that.’ The therapist said that although in life it is not possible to avoid losses and resentments they cause; they could pay attention to Eva’s feelings about it.

In a team meeting the following week the family therapist said that the termly meetings with the family had been going well but then at the last meeting a row erupted between Eva’s parents over her wish to change names. She thought there was obviously a lot of animosity between the parents over the issue and they didn’t seem able to discuss it in a reasonable manner. The therapist pointed out the way Eva and her father seemed to back each other up, while Eva’s mother’s point of view was not sought out. They all agreed that this often happened, as Eva's mother was very involved with the brother and her twin sister while the father was closest to Eva. The therapist made the point that Eva might feel she missed out on a close relationship with her mother. In response to this comment, Eva sat in silence. The therapist felt this comment hit home.

During the last phase of the treatment Eva described her excitement at going to university; she was sad to leave the therapy but felt much more settled in herself. Arguments in the family between Eva and the parents seemed to have settled down and Eva described herself as having a slightly better relationship with her mother who now took more care to spend some time with Eva.

Discussion of the case

Eva had not been able to manage her feelings of neglect, especially by her mother, who was preoccupied with her older brother’s illness. She inhibited herself from expressing her anger and hostility as she worried it would damage her mother. Her father's tendency to hover in the background when the brother was difficult, meant that she did not believe her father was sufficiently robust enough to support her mother. Instead, Eva cut herself off from her claim to a place in her mother's heart, believing that she had no time for her. This turned into a grievance against her mother for failing to make room for her and against her father for failing to support her mother. She tried to eradicate the hurt, sad, angry little girl by identifying with a tough, masculine character who was all action, with no soft feelings. This structure developed further when she spent time with her father, who also admired her toughness and athleticism.

The idea of her transitioning gathered momentum when this somewhat neglected little girl, so desperate to be loved and accepted, cottoned on to the idea that her father would have liked a sporty son. In this way, the fantasy would be that she would become a tough little boy who had no feelings at all. This deep-seated yearning was the cause of so much anger and pain, feelings that had gone unacknowledged by Eva or anyone else until she started therapy. In its place, she developed a cold, hard, defensive structure which protected her any feelings of vulnerability.

This was conveyed in the session when Eva talked about the film shown at school. It became apparent to the therapist that Eva was more identified with the cruel boss than the vulnerable young people in the factory. The therapist felt carefully watched by Eva as she told the story and noticed that Eva smiled at the cruelty she was describing. In this way, the cruelty was re-enacted in the session. It was as if Eva was saying unconsciously, "You thought we were working together in my therapy, but really I just exploit your softness and enthusiasm for the work. I am more like the boss who exploits vulnerability than the poor young people who are being exploited."

In his description of perverse organisations, John Steiner describes the way that vulnerable aspects of the patient who needs therapeutic help may be controlled by sadistic and cruel parts of their personality. He described the way this perverse structure can be acted out in the transference/countertransference (see pp. ) as the patient cruelly attacks the vulnerability and softness located in the therapist. The therapy’s task is to expose the way sadistic aspects of the personality hold vulnerable aspects of the personality to ransom and that this needs help and attention to resolve.

The therapy provided a space where the professional team could examine what was going on for Eva, exploring the phantasies behind her wish to transition, including the origins of her hatred of her gender. The deep-seated nature of Eva's difficulties meant that it took a long time for her to emerge from her psychic retreat. She also needed to experience the support of the therapist in exploring her feelings concerning the therapy in the first instance, then in relation to her family of origin. The cycles of engagement and resistance had to be endured, explored, and challenged. It was important to take up the role Eva's cold hostility played both in relation to the therapist and towards her own development.

Eva started therapy wanting to be transitioned into a new identity. She felt this would eradicate the unmanageable feelings she felt towards her parents for failing to provide her with a proper place within the family. She wanted to change her gender and her given name to enable this. However, the therapy offered a space where she could explore her internal world and find another solution to her conflictual feelings towards herself and other members of her family. Over time, Eva was able to see she could express irritation and aggression when she was disappointed with her therapist and that this did not amount to a disaster. Being more in touch with her negative feelings allowed her some room for development. She was also less fanatical about her plans to eradicate the little girl in her.

The announcement of the end of the therapy revived the argument about changing her name again. This caused a rift between the mother and the father. Initially Eva, perhaps unconsciously, provoked an argument between the mother and the father as a way of externalising her ambivalence about her wish to transition. This would protect her from arguing in her own mind as to whether she wanted to distance herself from the rather unhappy little girl who felt she had lost her mother to her brother. The argument between the parents represents the two parts of herself. Her father’s position says, ‘Escape painful feelings of loss’, while her mother's position can be in touch with the experience of loss as part of the mourning process. The conflict emerged again temporarily due to Eva’s fear of losing the therapist who had supported her to a better understanding of herself. Eva had increased her capacity to think about things rather than act them out and her social relationships and sense of herself had improved as a result so that she was less isolated both in her own mind but also in her external life.

Discussion
As Money-Kyrle wrote in his 1971 paper on the facts of life, some children find anxieties about the difference between the sexes and the difference between the generations difficult to manage and they find themselves being pulled into psychic retreats that offer illusory control over the developmental process. Part of the developmental struggle in adolescence is to come to terms with the reality of who we are, including our natal sexuality and the different roles demanded of us in reproduction.
“A normative developmental task is to integrate pubertal change into a revised and satisfactory body image” (Laufer & Laufer, 1984).

Conclusion
We believe that the desire to transition is often related is related to a wish to control sexual development, perhaps to put a lid on it and many detransitoners say that there is very little talk about sex on the pro-transition websites or in the medical care they receive. They report that biological realities are largely ignored in gender identity services. One detransitioner reported: 'Lots of talk about gender politics and none about the physical realities involved in transitioning'. Hence perhaps, the services are providing a reassurance to young people that anxieties about sexual development can be removed by gender transition. We would argue that this confusion and distress can be a normal part of adolescent development and over time, the individual could be helped and supported in becoming a fully functioning sexual adult who can enjoy what their natal sexual body has to offer.

Those in positions of authority in relation to the adolescent may often feel they are being provoked into retaliating, on the one hand, or collapsing into agreement on the other. The concrete nature of the communication can provoke concrete reactions and a projective system is set up as unconscious communications get pushed backwards and forwards between patient and therapist. It is especially difficult to maintain a calm, reflective state of mind when the patient is threatening to take drastic actions that the adult/professional may (rightly) perceive could be damaging. It is challenging when pushed to offer black and white responses or asked to give concrete direction in a ‘for or against’ manner. Supervision is essential when working with these disturbed and disturbing states of mind as even the most experienced therapist can be provoked into enactments. Supervision can change a dyadic projective system into a triadic one as the supervisor can retain the potential for restoring the capacity for symbolic thought. The adolescent needs parental figures and therapists to help them think about the underlying issues that might be driving them towards action.

The task of adolescence is not to become someone else, but gradually to discover whether one's developing body, emotions, relationships and identity can be brought into a more bearable relationship with one another. Psychotherapy cannot decide who a young person should become. Its task is to create the conditions in which they are free to discover that for themselves.