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The first and discomfiting task in commenting on this case is that one immediately confronts the challenge posed by a patient for whom the reality of the gendered body is problematic. To whom is one speaking? The disavowed Eloise has been banished. ‘Alex’, a name which does however suggest an ambiguity of gender, wants to be seen as male and referred to as ‘he’. The therapist believes that being addressed as a boy has been a ‘significant relief’ to him, and led to general improvement in his state. This is a very striking observation. It suggests that the dissonance between Alex’s sense of himself as a person and the perception of others was very painful to him. He is relieved when he can assert his sense of reality in opposition to what others think they see.
However we hear immediately of the feminine quality of his physical presence and that he and his family have decided against halting female pubertal development, so we are made aware of the female body simultaneously with its denial. Alex also lives in a world of other girls at his all-girls’ school (it is not so clear how he is addressed in the school context) and his friends are all girls.
We learn that Alex’s difficulties have been there for some years, but the context of their onset is not known. There is no early history to help our thinking, but we may be able to explore some ideas about the missing background from the clinical material. What we do know is that fatigue, poor sleep, anxiety and eating difficulties are all ongoing problems, his academic achievement being outstanding nonetheless. School looms large in that the previous term’s therapy was severely disrupted by exams, school life, and work experience. Alex’s capacity to assert the terms of engagement can thus be seen to set the scene within the therapeutic relationship as it does elsewhere.
The session presented follows the summer break. Alex starts at once as if welcoming the therapist to the renewal of their conversation. The therapist responds