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I welcome the chance to comment on this case, which raises a number of difficult, interlinking clinical and ethical issues. It would be impossible to discuss a case like this without being acutely aware of the fraught political climate currently surrounding gender dysphoria. On the one hand clinical protocols designed to protect trans-people from the danger of ‘conversion therapy’ and ensure access to medical treatment have recently been established (MoU, 2017). On the other hand there is a danger that effective psychoanalytic work with gender dysphoric individuals could be closed down for fear of falling foul of such protocols and/or being accused of transphobia (Withers, 2018). The therapist working with Alex faces the difficult task of attempting to sensitively navigate a path between these dangers.
Alex tells his therapist that he hates conflict and ‘very often ends up crying’ when someone such as his father or a teacher shouts at him. This makes him unable to stay composed or argue back as he would like. He becomes affect dysregulated. He seems to cope with this by ‘identifying with the aggressor’. “My inner thoughts” he says, “take the side of whoever attacks me”. He then thinks of himself as an ‘idiot’. This turning of his anger back against himself results in a dissociation from the sadness and vulnerability which he then experiences as ‘not really himself’. By contrast he was so happy when identifying as male on the internet that ‘he decided he wanted to do it for the rest of his life and came out’. Does
challenging the obvious defensive aspect of this male identification open Alex’s therapist up to accusations of attempting to practice trans-conversion therapy? How is a clinical supervisor to approach this risk?
Alex is clearly very aware of the power his trans-identification gives him and talks about how he can use it to ‘shut people down’. At one point in the session under consideration the therapist talks of ‘Alex creati