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Firstly, I would like to thank Karen Herdzik and David Solem for discussing this emotionally charged, controversial but important subject with me. Thanks too, to the Journal for enabling our discussion. At stake, I believe, is the safety of those young people who seek ‘gender affirmative’ medical treatment in the mistaken belief that it will relieve psychological issues such as autism, body hatred, early relational trauma, dysregulated affect and internalized homophobia. It may well be that not all gender dysphoric young people seeking medical treatment are like this. But my clinical and research experience suggests that many are and, so far, it has proved impossible to find a reliable way of distinguishing this group from those who are ‘truly trans’. My article then, seeks to address some of the difficulties encountered when trying to engage analytically with trans-identified clients' underlying, and/or co-morbid, psychological issues.
Solem highlights the importance of adopting an analytical attitude in such work. I utilize Winnicott's famous (1949) paper, ‘Hate in the countertransference’, to identify some of the countertransference difficulties. I also use a lesser-known (1947) article in which Winnicott argues that good results sometimes come from electroconvulsive therapy (ECT) and lobotomy, not because of their physical effects, but because they express society's unconscious fear and hatred of severe psychological distress. The violence of the treatment renders patients more socially acceptable and this can make them feel better. In my article, I argue that similar dynamics may occur in transgender medicalization.
Herdzik, in contrast to Solem, takes issue with several specific points in my paper. So, the rest of my response is primarily directed to her. I would like to begin by noting that both a consideration of the body in relation to the Self, and the unconscious in relation to identity, are conspicuous by their absence from Herdzik's account. I can proceed