I am a psychotherapist who has worked extensively for more than a decade with transgendered people. I have been around people who were transitioning for much of my adult life, although when I was growing up during the 1960s in the north of England, they were still rather rare. There was at that time a loosely defined gay community in the area where I lived that included some people who were transitioning. I knew two people, a man and a woman, each of whom was transitioning in the opposite direction. Both desisted, interestingly enough. One of them lived for two years as male, taking hormones, then reverted to living as female.
I had undergone many years of psychotherapy before training in it myself. I originally trained at the National College of Hypnosis and Psychotherapy and had a very broad, very general training. My own therapist was trained in psycho-synthesis, and I became deeply interested in transpersonal therapies. I have done foundation training in Jungian analytical psychology, which informs my work today. Looking back, I think it was partly the spiritual side of things that attracted me. Ken Wilbur talks about how there are different levels of consciousness: every level knows its own level and those below, but knows nothing of the levels above.
It never crossed my mind that someday I would get involved in transgender counselling. But about 18 years ago a friend of mine asked me if I would become a trustee of the Beaumont Trust, a charity which came out of the Beaumont Society, established in the 1960s to support and educate the public about transsexuals and cross-dressers. Then, in my mid-40s, I studied for a degree in Chinese at the University of Westminster. For my research dissertation I chose to interview transgendered people across China, Taiwan and Hong Kong. No one else seemed to be doing research in this area of Chinese culture. As a result of this, I travelled to Hong Kong, thinking I might do an M.A. at the university, and while I was there I met a professor who was involved in transgender rights in Hong Kong. He invited me to present a paper presenting my research at the first conference to be held in Asia on the subject of gay and transgender rights, in Bangkok in 2004.
So my interest in psychotherapy came together with the research that began with my degree. I worked with a private gender clinic in London, which offered all services for transgendered people including psychotherapy. At the beginning, only about 20% of my clients were transsexuals. By the end of my work there, 80% of them were (I also maintained a private practice outside of the gender field). I work with the person that’s in front of me: I don’t work the same way with everybody. With gender patients who are considering treatment, there are different things to consider. A mental health assessment was, at the time, recommended by public health guidelines before medical interventions could be carried out. Older research suggests that the median age for patients presenting at gender clinics for transition used to be around 41‒42 years old, and largely natal males; these studies predate mass use of the internet.
However sometime around 2014, it became apparent that this was changing. Three years later the median age dropped, and where the majority of patients used to be natal men, by 2017 it was the other way around, and three times as many natal females who wanted to be men were coming forward. So it started with a greater proportion of middle-aged men, but by the end there was a greater proportion of very young women in their late teens and early twenties. In 2017 alone that curve went up dramatically and no research was being done into why this was happening.
The transgendered field is on the whole very under-researched. Very few clinicians or psychiatrists have chosen to become involved with it. Recent research has tended to be sociological rather than clinical: so there are lots of studies into how oppressed transgendered people feel, how discriminated against they are, studies about their sexuality. But virtually no research into the clinical reasons for wanting to transition. Clinics in the Netherlands and Belgium have all called for this research, but few people seem to be picking up on it.
Kenneth Zucker, a Canadian psychiatrist who ran a child and adolescent gender identity clinic in Toronto, has done more research into child and adolescent gender identity than anybody else. His clinic was shut down in 2015 because of pressure from political activists. He urged extreme caution in facilitating children to live in the opposite gender role. He advised parents to encourage children to remain in their original gender role, and only then move them forward into transition, should they persist in their cross-gender identification over a long period. His research, and that of others, shows that around 80% of children who are not put on puberty blockers, and who attend gender identity clinics, do not go on to transition: most are gay and go on to live gay lifestyles.
In the UK, at the Portman and Tavistock Child and Adolescent Gender Identity Clinic in London (the only NHS gender clinic for under-18s in the UK), about 12 years ago approximately 6 children a year were being referred. In the last year 2,300 were referred. The number has doubled every year over the last decade. I think it’s important that we use facts and observation in developing our understanding of this phenomenon. We need research because we don’t know why these hugely increased numbers are happening. Has mass use of the internet accelerated it? We need the research in order to find out what is going on. Just recently Penny Mordaunt, the UK Minister for Women and Equalities, has launched an inquiry into the huge surge in girls wanting to transition.
In 2014 I was having a drink with Miroslav Djordjevic, a professor of urology who also does gender reassignment surgery at the University of Belgrade School of Medicine in Serbia. He told me he had had several requests from male to female reassigned people to reverse their surgery. He said he thought that somebody needs to research why this is happening. In the past, studies suggested that the rate of regret among those who had transitioned was between one and five percent. The general attitude among people involved in the transgender world was that it was so low that it wasn’t really important. But this was based upon old research from the ‘80s and ‘90s. My preliminary research suggested those percentages were massively out of date.
So at the start of 2015 I enrolled for an MA in Counselling and Psychotherapy at Bath Spa University because I knew the bulk of the degree was a research project, and I wanted to research the reasons why people decide to de-transition and reverse their gender reassignment surgery. I put notices out on the internet: some people contacted me saying they were so traumatised by what had happened they didn’t want to talk about it. I was also contacted by a group of young women in the US who had transitioned to the male gender, had double mastectomies, taken testosterone, etc. They then transitioned back, but they didn’t reverse their surgery, they said they would just live with the scars rather than having implants. Under the parameters of my research project as originally specified, I couldn’t include them in my research. So I went back to the university and said I want to include subjects who didn’t have reconstructive surgery when they de-transitioned. I was told I had to resubmit my proposal, and then told at the end of 2016 that I couldn’t do the study at all. They said that undertaking this research could result in criticism of the university. They wanted me to change my research proposal. I refused and lodged a complaint. In 2017 I took legal advice and began the process of taking the university to court.
This coincided with transgender issues looming even larger in the media, and also with public policy changes. The Equality Act affects people with protected characteristics—which includes those who are undergoing gender transition. But no one is completely sure who that applies to. So, for instance, the clothing retailer TopShop made their changing rooms unisex, because a man who was wearing women’s clothing wanted to use the women’s changing room, was refused and complained. Similarly with the Girl Guides: any boy living as a girl will now be housed in the girls’ dorm. No one wants to be sued under the Equality Act.
It is now being proposed to change the Gender Recognition Act to legally recognise the self-declaration of gender, which would mean that sex and gender would become defined by what a person thinks and feels, and not by their body. In the UK, since 2004, in order to get a Gender Recognition Certificate allowing a person who has transitioned to change their birth certificate to their “acquired” gender, they have to have lived in that gender for at least two years. Two doctors have to vouch for them, and one of those must be on the Gender Recognition Panel’s list of approved doctors—so in effect a gender clinician. We have a situation where policy and law are being made without a full understanding of what is going on. In addition, trans has become a rallying point for people who have a political agenda. This has a lot to do with the meeting of social justice theory and identity politics.
But from a clinical point of view, it is worrying: standards of care for treatment have been hugely liberalised in a move to make things easier for transgendered people. There’s been pressure for many years to make it easier to transition. In the last Standards of Care issued by the World Professional Association for Transgender Health, which sets the international benchmark for treatment, the requirement for counselling before treatment was removed. These are not rules, they are simply recognised standards for the medical profession, but this shows how the idea has grown that it is oppressive for transgendered people to have to prove their need for treatment. The move is towards treatment on demand, particularly in the USA, where the “affirmation” approach to treatment is being embraced. Yet the only way you can have treatment on demand is if doctors abdicate their responsibility of care.
What the de-transitioning women I have spoken to are saying is that they felt they had been drawn into a “movement”. It was very exciting, it gave them a place to express themselves, and they were encouraged by their peer groups to have gender transition treatment, which was easy to get in America where the “affirmation” approach within clinics is quite usual. Then they found that this didn’t solve their problems. Many of them had had mental health issues, many had been sexually abused, they hated their bodies… They felt that their female identity had been compromised, but neither the ideological context in which these young women were living, nor the clinics they attended were able to address this.
I went into therapeutic work in order to help alleviate suffering. Clinicians, psychotherapists, doctors all work to alleviate suffering. When I first became a psychotherapist, there were a tiny number of people who had suffered so much and had struggled so long with how they felt about having to live out their gender, that they really felt the need to transition, physically, to the opposite one. But that’s a very extreme solution. The psychological motivations and emotional reasons for people going to gender clinics are hugely varied and complex. For instance, research shows that there is a very high ratio of people on the autistic spectrum presenting with gender problems. Autistic people, of course, have problems with the issue of “role”.
There are those who want to prove that gender is entirely neuro-biological, that gender identity resides completely in the brain, from birth. For instance, the Gender Identity Research and Education Society in the UK seeks to prove that this is the case. Therefore, there’s nothing you can do about it: you can’t be “cured” of it, it’s part of you, a natural difference in someone’s brain. You can’t change the composition of the brain: so, in order to help a person with that kind of neuro-biological make-up, you change their body to match the brain. They are seeking to prove that gender identity is not a choice. I think that it’s possible that neuro-biology plays a part for some of the patients I was seeing. But no one has proved this definitively, and in addition, there is clearly a large social and cultural element in what constitutes gender.
These days, I have de-transitioning people contacting me on regular basis. I don’t believe that one is “transphobic” for listening to them and giving them a voice. There is nothing to fear from talking to those who regret transitioning or are critical of it. We need to know the truth, and once we hear from a spectrum of people it’s going to be a complex picture. The method I was going to use for my research is called phenomenological analysis. It means letting people speak for themselves. The researcher must stay out of the way. I simply wanted to give people a platform to be heard.
From a Jungian perspective, I think we need to understand how the collective unconscious comes into this. We need to get at the deep reasons why this political bandwagon has gathered so much momentum. We need to understand this “shadow” phenomenon where people who question are vilified and silenced, and people are afraid to say what they think. It comes up time and time again throughout human history. Why has gender now become such a political flash point? It has become impossible to have a critical discussion about it. Critical thinking is being confused with criticism, and criticism is being confused with attacking people. Maybe the “shadow” of liberalism is repression: we are not allowed to think, let alone speak, critically. Jung would say that some things come out of the collective unconscious, manifest, then subside again. In the meantime, we need to be circumspect with how we allow these manifestations to affect vulnerable individuals, and we need to allow people to talk, and to question.
James Caspian is a UKCP registered psychotherapist, with a special interest in Jungian Analytical Psychology, who maintains a private practice in the South of England. In order to defray his legal costs against Bath Spa University, James Caspian has set up a crowdfunding page.
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