This article is an edited and slightly modified version of a presentation given on 12 March 2017 at the Conference on “Transgender, Gender and Psychoanalysis” organised by The Site for Contemporary Psychoanalysis and the Freud Museum, London.
Embodiment is about the body. It is physical, specific, concrete. There is no reason to restrict gender variation to the genital, the hormonal or the sartorial. In this essay, some examples are discussed of the practical consequences of variations in how people express and embody their gender concretely rather than symbolically. What consequences does this have, ranging from the personal to social and political impact and risks, and to the psychotherapeutic consulting room? It is concluded that psychotherapists should bend over backwards to be sensitive, strictly non-pathologising and client-focused in anything to do with gender – gender presentation, expression, embodiment or identity.
At the presentation of this paper in its original talk form, the speaker appears, dressed in a jacket, somewhat formal. He has red lipstick and wears rather extravagant earrings. He moves to stand fully visibly in front of the audience.
I am Dutch. I am a Muslim. I am male. I am a psychoanalytic psychotherapist, but relational, not classical.
The speaker relaxes a bit, and unbuttons his jacket. This makes visible that his fly is undone.
I am not a psychoanalyst at all, and not a member of the Institute, of course. I am not Lacanian either.
A person appears from the audience, who whispers something in the speaker's ear. The speaker responds with a startle, his hand covers his crotch, and he does up his fly.
I was not Lacanian either when I was 2 years old. Or I did not feel I was. In fact, I am a bit vague about it, and do not quite remember, but
I do not think I was. As best as I can make sense of it. I have asked my parents, when they were still alive, if they were sure I was not, and they were no real help. But maybe they were embarrassed at the thought too, and wanted to spare my feelings, and avoid upset in the family. I thought about it a lot during puberty, I read endlessly, and I had one friend with whom I dared share the idea. But in the end, wisdom prevailed. I did not come out, I did not hint at it. I did not want to deal with the trouble.
By now some of you may wonder what the hell is going on… And why I keep going on and on about my status of being a Lacanian or not.
Why, at a deeper level, do you not really care to know about the history of my status as a Lacanian or not? I submit that that is because you want to hear what I have to say, if anything, and believe that your evaluation of my talk, and of me as a person, is only very marginally influenced by knowing whether I am Lacanian or not. This audience is a very privileged one, in that it includes many people who would have some sense of how my ideas could be influenced by being Lacanian. But even those knowing that would realise that it would only be a guess, not a certainty. So you would rather that I got on with it than telling you more about a relatively minor and unimportant qualification pertaining to me personally.
How about me? For me it is not a real issue, as I would not be afraid of admitting that I was a Lacanian, if I was. Being a Lacanian is not a protected designation in the UK, or in any countries I know. It is not included on my passport. No countries ask for it on their visa forms. No countries put the death penalty on being Lacanian. If the British authorities would want to deport me for being Lacanian, as opposed to being Dutch post-Brexit, I would need to accept it. I could not plead that I would be exposed to persecution in my home country for being Lacanian, so the authorities could not give me the third degree to force me to prove that I really am Lacanian, as opposed to feigning it to get refugee status.
How would I prove that I am a Lacanian? It is no different from me being Dutch or Muslim - there would not be bodily markers to show it (though my difficult-to-shake Dutch accent might be a give-away; and
being circumcised or not, and the precise physical form of circumcision, could be substantial supporting evidence about being a Muslim, without being entirely decisive).
So with this bit of concrete action, I wanted to make you think about how you know someone's identity, and about why it matters - and apply that specifically to the contexts of gender and trans, in today's society.
How is it with being female or male? When I appeared, and so far if you saw me during this conference, was there any doubt in your mind that I was male? Is there now? If I said that I am a woman, would you believe me? Given the nature of this conference, and that I now suddenly wear lipstick and earrings, do you start having some slight doubts that there might be something strange, anomalous, perhaps slightly “perverse”, something “queer”, about my “gender identity”? Could it be that I am at least a cross-dresser at home? Perhaps I have an “atypical gender expression”, am “gender-nonconforming”? Perhaps I have an “emasculinisation desire” and could be on my way towards developing an “alternative non-malenonfemale gender identity”? All these latter terms are used in the new DSM-5 (APA, 2013), which has been in touch with a surprisingly modern series of ideas, as evidenced by this panoply of linguistic options.
However, I submit that before drawing any conclusions from the hint provided by my superficial and non-genital/non-sexual signs, you would want to talk with me, and hear me about me – rather than first ask me to take my pants down and inspect my genitals. Regrettably, DSM-5 (APA, 2013) continues to put a lot of emphasis on “sexual anatomy,” on “sex characteristics,” on “biological indicators of male and female,” amongst which they classify “sex chromosomes, gonads, sex hormones, and nonambiguous [sic] internal and external genitalia.” Despite all the discussion that went into the change from “gender identity disorder” to “gender dysphoria,” the American Psychiatric Association (2013) could not bring themselves to drop the separate chapter “Gender dysphoria” from their manual of “mental disorders,” nor could they even once use
the word “non-binary gender,” which appears to be much more typical for genders other than full-on cis-male and cis-female, and more palatable than the wordings they seem to prefer of “atypical gender” or “non-conforming gender” – although, in one section, they do use the rather lengthy “alternative gender identities beyond binary stereotypes” and once-off even the rather nice “desire to be of an alternative gender.”
The horrible reality I want to draw attention to is that it is highly dangerous to be trans (Serano, 2013) – as opposed to being Lacanian. There is a small start finally being made to statistically capture the numbers of people being killed because they are trans. The numbers identified so far are already large, and as the reporting improves, they are likely to be growing. Even some acquaintance with men who like to cross-dress at parties in London will immediately bring out the risk they run when returning home of being beaten up on the way, if they do not change into male or “invisible” clothing. Considerably more attention has been given to women who feel at risk when they return home via public transport after partying and are worried for their safety. It is unacceptable for anyone to need to worry about their safety when walking on the street or in public places at night, because of how they dress or who they are.
How many trans people are there in the world? In the UK? In London? The real scientific answer is that we have no clue. Statistics in the past moved seamlessly from asking “how many trans people” to “how many people with gender identity disorder.” But this is not at all the same thing. Only very recently does attention start to be given to people who are in some way gender variant or genderqueer, but who manage their feelings in such a way that they are not identified in statistics, or with services, and who are not prepared to take the risks and deal with the disturbance still caused by having a full formal medical transition including surgery. These are people who know that their own sense of their gender does not simply coincide with what society seems to determine about the gender they were assigned at birth, but do not feel an immediate need to do something about it, by physically modifying their body.
Do all or most people who are trans in this general sense want to “transition” completely, physically, surgically? Or even want to have hormones prescribed to them in certain quantities? How will we properly find out, when the dangers involved in being trans in public are as great as they are?
In a number of ways it is becoming apparent that many more people than identified so far have some discomfort or unease about the gender they were assigned at birth, and at least some “gender variant” self-identification. The Gender Identity Research and Education Society (GIRES) in the UK has done some excellent work in this field. Based on a period of study, the results of which were published in 2009 and 2011 (Reed et al, 2009; GIRES, 2009 and 2011), they give a very broad estimate that perhaps 1% of the UK population may be “experiencing some degree of gender variance,” of which they think perhaps 0.2% may “at some stage undergo transition.” That would leave four times as many non-transitioning gender-variant or non-conforming people as there are people who are transgender/transsexual in the usual more restricted sense of the words.
Of these people, a good proportion can probably best be described as “non-binary” – whether or not they would like to use this word to describe themselves. Some good recent articles about non-binary gender are Barker and Richards (2015), Richards et al. (2016) and Stewart (2017).
It may be useful here to add a distinction between self-experience and identity. For instance, in a recent study in Israel (Joel et al., 2013: 20), it was found that “a large proportion of ‘normative’ [essentially, non-queer] [people] experience themselves in ways that transcend the either/or logic of the gender binary system.” While being in most ways “registered” as having a clear male or female identity, more than a third of the people studied in this research at times experienced their gender as different from their official gender identity.
Indeed, simply based on personal experience, amongst students at secondary schools and universities, and amongst younger people in general, there is a rapidly expanding sense that gender is more fluid than it was ever thought to be, and either that gender of self and others does not
matter that much, or that it is seen as natural that a person's sense of their gender fluctuates and/or is stronger at some times than at other times.
My experience is that a substantial number of contemporary people, when given space and a safe listening ear, will be reflective and thoughtful about their self-perception of their relationship to themselves and others as gendered. And many will have some variation, changes, wobbles and idiosyncrasies when they reflect on that. It feels more like in a range of 10 to 25 % to me personally, than 1% – but one is very influenced of course by the clients one attracts. Just working with the GIRES data, there clearly are many more people who have a “trans” element in their gender make-up than who want to transition. Let us think about that some more.
In the title of my paper, I said I would talk about the embodiment of gender. Embodiment comes from body. Changes and variations in the body can also be formulated as “body modification” – another somewhat loaded term. How many kinds of body modification are there - how many do we consider?
Firstly we modify the body aesthetically, visually, and in other ways, in countless ways on a daily basis. We get dressed – which humans did not do before the advent of “civilisation”– we wash, comb and otherwise modify our hair; we cut, shave or remove our hair in various places; we use perfumes and deodorants; we use soap, creams and forms of make-up to modify the skin, its feel, its smell and its appearance.
Most forms of medically recommended surgery by definition are accepted without much question. They are sanctioned by higher, expert, medical authority as necessary to support our health – and what else can a psychotherapist do than be in support of health? Similarly we rarely question the ideas of spectacles to correct eyesight, or prosthetic limbs. What about teeth? No one says that to let teeth rot and fall out would be more “natural” than the usual practice in modern countries. But what about the years of orthodontic treatment for children in early adolescence, to make sure they have attractive teeth and a “beautiful smile”? Is
there much doubt that this will be more often recommended to girls than to boys? Is it necessary for health? Is it natural? But it is only rarely criticised by psychotherapists (or others) as in need of reflection, if at all. The same goes for other obvious “remedial” treatments of things like cleft lips, children born with six fingers or toes, port-wine stains or birthmarks in the face. As often as not, attempts will be made to “repair” them, without much criticism or debate as to possible doubtful unconscious motives, let alone about “pathology.”
It is worth specifically noting that when cisgender people have surgical procedures or hormone treatment clearly related to their gendered appearance, this is not psychologised or pathologised, but seen as “medical” and “natural.” I am thinking here of breast reduction for men troubled by gynaecomastia; hair removal or implants; female breast implants after they have been removed because of breast cancer; taking steroids to influence body shape, or HRT for its beneficial effects.
Now jumping to the other end: Tattoos. Piercings. Cosmetic surgery, more pleasantly euphemised as plastic or aesthetic (Mendelson and Steggall, 2013; Gilman, 1999) surgery. The co-called “boob jobs” of actors, major or minor celebrities and porn stars. I will not say much about the series of circumcisions for reasons of Muslim or Jewish faith, or American cultural reasons. Or female genital mutilation for a mix of cultural and perhaps religious reasons. This is where a split originates. Many psychotherapists draw the line here, and whether or not they go to formal diagnoses, or think about particularly pointed terms for what is wrong, they will, in one way or another, be influenced by the thought that there is something wrong – doubtful – and questionable about these practices.
I think it behoves us as psychoanalysts and psychotherapists to consider our countertransference very carefully, before wading in and “exploring” our clients' feelings about such “doubtful” kinds of body modification, before we do so and find that unconscious to unconscious, body to body, our client hears loud and clear that we are convinced that what they do or intend to do is wrong, very wrong, pathological, and that the only successful outcome of psychotherapy is that our client sees the light, understands the pathological background to their misguided wishes,
and gets access to a strong dosage of spontaneous motivation to make the “right” decision for themselves – which inevitably would be, not to make the body modification. This was of course also how it worked in the days when, 50 years ago, many psychotherapists and analysts reacted like this to clients who would share with them their “homosexual” inclinations or behaviour.
A third class forms a series of even more clearly proscribed and proscribable categories:
“non-suicidal self-injury” as named by Favazza (2011), with more durable self-mutilation as a subcategory;
suicide attempts;
consciously risking self-harm such as in boxing, climbing Mt Everest, possibly rugby and pro-football, and certain other sports and martial arts;
more or less superficial injury risked or actually caused by BDSM/kinky activities, including erotic auto- or allo-asphyxiation
How can we look at different variations on the theme of bodily change for reasons of gender self-perception, expression or identity, and compare them with these other acts of influencing, changing, or modifying the body?
And what and who determines whether acts of body modification are right or not? Mostly seen as positive, such as washing and medically prescribed surgery; neutral; or negative? Pathological? Perverse or taboo? I submit, without being able to analyse it or do justice to it in this limited space, that it is mostly the body modification of others distant from us that we condemn, and the modifications of ourselves or those close to us – family or our in-group or community – that we approve of and find natural and evidently reasonable and well-motivated. Some suspicions I have about the criticism by many feminists of make-up and of cosmetic surgery I would include in this category. But in the same way, I cast suspicion on the pathologisation of BDSM and kinky activities, which finally – at least partly – has begun to be questioned and has been substantially reduced in the latest revision of the DSM-5 categories and their definitions (APA, 2013).
Against this wider background, I would draw two conclusions about how trans people view, think and feel their body and their gender:
It is safer, saner and more respectful to believe that people are in charge of their own bodies, and allowed and even encouraged to make decisions for themselves about their body and their gender.
This judgement includes the question whether changes, modifications or adjustments are reversible or not, superficial or profound, visible or not, and whether they are outside the skin, or include the internal systems and organs, such as hormone treatment and surgery involving genitals or the shape of body parts such as breasts, but also facial characteristics.
Just as a revision of the traditional substantial pathologisation of the so-called perversions and later paraphilias was a major change, and a challenge to psychoanalytic thinking especially, seeing the changes that trans people make or think of making to their bodies, appearance and expression as their private business, is a radical step that will feel threatening to many practitioners. It is not easy to deal with one's countertransferential response in all these cases, and the simple ethical stricture that, if you cannot control your personal countertransference, you should not work with certain people, applies to all examples of that – working with kinky clients, with gay clients, with bisexual, pansexual and queer clients, with self harming clients, with suicidal clients, with asexual clients, with clients with eating disorders, with clients who are very rich or who are very poor, with clients of ethnic backgrounds that we are unfamiliar with, and with clients who are trans. Valerie Sinason has been an inspiring example to me in talks she has given, saying that everyone, however experienced in working with trauma survivors, has certain traumas that they are so uncomfortable about dealing with that they need to excuse themselves. And of course, so much the better if we have a wide range of clients with whom we can work effectively. But the client's interest must come first.
Much as I enjoyed Lemma's book about body modification (2010) and agree with parts of it, it will be clear that, overall, I disagree with the
broad range of the conclusions she draws from her work, especially that “… from an analytic point of view we would understand [the] decision [of the patients I will describe in this book] to alter their bodies as being guided by the ascendance of a psychotic process in the mind.” (Lemma, 2010: 3). However, I go along strongly with her recognition of Freud's understanding of the ego as body-ego, and her quotation of the words of Rey (1994), “in every analysis one has to arrive at the body-self if one wants to achieve deep and enduring change” (quoted in Lemma, 2010).
There is a long history of trans people, preceding and certainly not fully dependent on the availability of late 20th century models of hormonal and surgical change (Stone, 1993; Stryker and Stone, 2016; Stryker, 2008). At the moment, the natural position of sitting with clients who start to talk about their variations and uncertainties to do with gender, is to allow for the possibilities that they see gender as binary or not, that they may want to make any type of practical changes or not, in private or in public, that they may go in the direction of how they present themselves, what pronouns they have others use about them, how they dress, how they present, whether they take hormones or not, and whether or not they want to make any changes to their hair, their skin, body parts and organs, or not.
It takes factual knowledge of options, experience, and of course empathy and sensitivity, when, how and to what extent elements of psycho-education, reading suggestions, participating in some groups or events, or direct exploration in therapy are the best form to choose. But the one thing that, in my opinion, is not called for, is to give any degree of importance to the personal judgement of the therapist or analyst about how the client wants to lead their life. Some people consider this a radical view only seen with existential therapists. I see it primarily as an ethical imperative.
I should make clear that I have not developed these views in the abstract, purely or mainly based on articles and books I have studied. I know and have known for a long time people in many of the categories and situations I mention. And I have worked and continue to work with trans clients, and clients who may or may not be trans but certainly
are actively exploring their gender. I am not averse to “following” clients when they want a letter from me confirming that I believe they can be diagnosed with gender dysphoria. I have followed clients when a couple present themselves with one spouse slowly reaching the conclusion that they need to largely move into another gender than the one they were assigned to at birth, and with which they concluded a marriage – and helped them to consider what could or could not be containable in their relationship and its continuity. I have affirmed as many clients as I could in believing that they can trust themselves and their bodies, far more than today's society, its laws, its culture, and the responses of their parents, family and religious community about how they should and should not think about gender. My experience is that this usually leads to a distinct decrease in the degree of violence found in fantasy and wishes – but even what one regards as violence is less objective than is sometimes thought.
This way of working has rarely, if ever, been easy, and certainly not easier than a more normative and judgmental position. But I believe it is the only one that is defensible from a position that believes in people being in charge of their own destiny, and that repeating the past is a deadening straitjacket. My views are substantially influenced by the views of Bowlby about the importance of the attachment system, of real events and the real relationship, and of the relational emphasis in contemporary psychoanalytic practice.
I believe parts of what I have said may sound radical, and be uncomfortable to some of you. Lacan, who has inspired many of the organisers of this conference, took the view that every age needs to look at people, society, and reality in its own new original way. And he never shied away from controversy. I hope that my ideas may lead to some further fruitful discussion.