Transgender Identities

A Contemporary Introduction

Alessandra Lemma

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000521184
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychanalyse

This important new book by Alessandra Lemma provides a succinct overview of psychoanalytic understandings, approaches and controversies around transgender identifications.

Illustrated with case vignettes, Lemma provides an up-to-date synthesis of current research and a critical overview of psychoanalytic approaches to transgender identities, distilling some of the contemporary controversies about how to approach the topic in the consulting room. Lemma also outlines a psychoanalytically informed ethical framework to support clinicians working with individuals who request medical transitioning and distils the ethical challenges faced by clinicians in light of the current emphasis on gender affirmative care.

Part of the Routledge Introductions to Contemporary Psychoanalysis series, this book is of great importance for psychoanalysts in practice, academics and all those with an interest in transgender identities and mental health.

Chapter 1

Research perspectives on transgender

DOI: 10.4324/9781003090724-2

Why start a book on psychoanalytic thinking about transgender with a chapter about research? It is not because I privilege research over psychoanalytic views on the subject. Rather, it is because research, notwithstanding its limitations, provides a useful background context for the exploration of the psychoanalytic ideas and controversies that will be addressed in subsequent chapters. Research is based on larger samples of transgender individuals than the single case studies psychoanalysis excels at. Both types of data are important.

Research studies do not provide any definitive conclusions because no research can ever be conclusive in an absolute sense and because research on transgender specifically poses many challenges. Many of the terms used, not least the term transgender itself, lack epistemological clarity. Given the nature of the transgender experience, control groups cannot be easily employed. Moreover, although transgender research studies are growing apace, this is a relatively new field with very few longitudinal studies. The latter are essential. Only follow-up studies allow us to address some of the key questions that tax clinicians: what are the pathways to transgender identifications and disidentifications, what are the long term physical and mental health outcomes for those who pursue social and/or medical transitioning, what kind of therapeutic response is most helpful when people report being transgender¹ and how can we improve the precision of the diagnosis of gender dysphoria so that we can more reliably identify children who are false positives.

The research overview is deliberatively brief because this text is intended primarily as a psychoanalytic orientation to the subject, not a comprehensive account of the state of play with respect to research. However, it is helpful to have an appreciation at least of some of the salient research concerns that can be pursued in more depth, if required.

Pathways to transgender identification

The ‘why’ question is core to a psychoanalytic approach. Its focus is appropriately on the patient’s idiosyncratic developmental history and internal world as a means to approach the meaning and function of a transgender identification. Beyond psychoanalysis, the ‘why’ question concerns nature versus nurture and is yet to be settled when it comes to gender identity. Though the aetiologies of cross‐gender identification and gender nonconformity remain elusive, existing data suggest that elements of both gender identity and gender expression result from a combination of biological and psychosocial factors. Any search of the literature will offer arguments for both sides of the conceptual divide. Taken as a whole, the evidence remains inconclusive and there is no theoretical consensus (e.g., Di Ceglie & Freedman, 1998; Roughgarden, 2013; Zucker & Bradley, 1995; Turban & Ehrensaft, 2018).

The idea that there may be a genetic component to transgender results from studies of monozygotic and dizygotic twins that suggest that cross‐gender identification is approximately 70-percent heritable (Coolidge, Thede, & Young, 2002; Van Beijsterveldt, Hudziak, & Boomsma, 2006). However, these studies are limited by their use of screening measures that fail to adequately determine if participants are indeed transgender. The role of prenatal steroid hormones has also been influential in supporting a biological view of cross‐gender identification. Research with animals provides some evidence that exposure to high levels of prenatal testosterone can result in XX animals exhibiting cross‐gender role behaviour (Hines, 2006). Studies of humans with differences or disorders of sexual development lend some support to this theory: for example, the vast majority of XY individuals with complete androgen insensitivity develop a female gender identity (Mazur, 2005). However, some have noted that these individuals are typically raised as females and that psychosocial factors may therefore play a role (Hines, 2009).

A number of psychosocial factors have been investigated as potential determinants of cross‐gender identification such as parental characteristics (e.g., maternal wish for a child of the opposite gender), paternal absence, and parental psychological functioning, among others. None of these hypotheses have been systematically validated (Steensma et al., 2013c). Psychoanalytic practitioners will be familiar with specific cases where a psychogenic formulation appears to be the most persuasive and I share examples of this in subsequent chapters. The absence of systematic studies validating such hypotheses does not imply that psychogenic explanations have no place in understanding transgender, but they caution us not to generalise or reduce a transgender identification to a single psychological developmental pathway. Indeed, taken together, the findings from both biology and psychology underscore that to understand transgender we need complex formulations that transcend any one discipline.

Psychiatric co-morbidity and suicide

With the move away from a psychiatric nomenclature framing a transgender identification as a disorder, the focus has shifted to exploring the mental health problems that co-occur and/or are exacerbated by a transgender identification. This research is more substantive, consistent and highly relevant to clinical practice.

The most common psychiatric conditions seen in transgender individuals are internalising psychopathologies such as depression and anxiety (de Vries et al., 2016; Skagerberg, Davidson, & Carmichael, 2013; Steensma et al., 2014). These conditions are thought to be consequent to a) the stress associated with belonging to a minority group, b) the dysphoria associated with one’s body developing in an incongruent fashion to one’s gender identity and/or c) the stress arising from family and/or societal reactions to this incongruity. Much of these data come from studies of young people who are referred to gender clinics. In these studies, mood disorders are present in 12.4–64 percent of patients and anxiety disorders in 16.3–55 percent of patients (Holt, Skagerberg, & Dunsford, 2016; Khatchadourian, Amed, & Metzger, 2014; Olson et al., 2015; Skagerberg, Davidson, & Carmichael, 2013; de Vries et al., 2011) and appear to worsen with age (Steensma et al., 2014; de Vries et al., 2011).

Some estimate that 80 percent of transgender adolescents are victims of bullying (McGuire et al., 2010). Poor relationships with peers have been found to be one of the most reliable predictors of internalising psychopathology (de Vries et al., 2016). Transgender adolescents and adults report significant levels of minority stress as a result of stigma, prejudice, and discrimination across the life span (Bockting et al., 2013), suggesting that social reactions play an important role in the psychiatric morbidity reported.

The real impact of negative societal reactions must be acknowledged and addressed at a societal level. However, we cannot exclude the possibility that some transgender individuals have pre-existing problems that are not the consequence of being transgender but instead may have contributed to the identification as transgender in the first place. For example, Kaltiala-Heino et al. (2015) examined referrals to an adolescent gender identity clinic in Finland over a two-year period. They found high rates of mental health problems, social isolation and bullying. Importantly, most bullying pre-dated the onset of gender dysphoria and was unrelated to gender incongruence.

Transgender individuals are significantly more likely to have attempted suicide compared to the general population. Transgender adults have lifetime suicide attempt rates of approximately 41 percent (Haas, Rodgers, & Herman, 2014). Studies have shown that adolescents referred to gender identity services are at an increased risk of suicidality, and this risk increases with age (Aitken et al., 2015). Amongst groups of transgender adolescents seeking hormonal interventions, studies identify a steep rise in the rates of suicide attempts with age: 9.3 percent by a mean age of 14.8 (Spack et al., 2012), 30 percent by a mean age of 19.2 (Olson et al., 2015), and a 41 percent among transgender adults (James et al., 2020).

There are disparities in suicide behaviour, underscoring the heterogeneity that exists within transgender populations. Consistent with some community-based studies of adolescents and adults, Toomey, Syvertsen, and Shramko (2018) found that transgender female-to-male (FtM) adolescents and non-binary adolescents reported the highest rates of suicide behaviour, exceeding the rates reported amongst cisgender controls. Furthermore, they identified that the intersection of sexual orientation and gender identity is associated with an enhanced risk of suicide behaviour (nearly 2 to 4 times higher odds compared with transgender adolescents who identify as only heterosexual). In addition, for most transgender subgroups, having parents with higher education levels and living in urban spaces did not appear to mitigate the odds for suicide behaviour as it did for cisgender female and male adolescents. Research suggests that parental and familial responses to transgender identity are significant correlates of suicidality (Grant et al., 2011) but that negative responses are not restricted to particular socio-demographics.

Autism spectrum disorders (ASD) are consistently overrepresented in children and adolescents who present to gender identity services leading some researchers to impute a relationship between ASD and gender dysphoria (Skagerberg, Di Ceglie, & Carmichael, 2015). ASD symptoms are present in 5–20 percent of gender clinic‐referred youth (de Vries et al., 2010; Pasterski, Gilligan, & Curtis, 2014) compared to approximately 1 percent of the general population who meets criteria for ASD (Lai, Lombardo, & Baron‐Cohen, 2014). The research investigating a possible link with ASD is problematic because it includes all-encompassing definitions of transgender (e.g., children who ‘sometimes wished to be the opposite sex’), making it very hard to generalise. Interestingly, in one study, the rate of cross‐gender identification was similar in a population with attention deficit hyperactivity disorder, raising the question of whether gender dysphoria and ASD are linked or rather that those with gender dysphoria are overrepresented in clinic‐referred populations generally (Strang et al., 2014). This is partly in line with the study of van der Laan et al. (2015), which suggested that specifically intense obsessional interests are one of the hypothesised mechanisms underlying the possible GD-ASD co-occurrence. Gender identity issues could result from ASD people’s preoccupation with unusual interests or gender dysphoria in ASD could represent OCD rather than genuine gender identity issues. It may also be that ASD children’s experience of being different and marginalised could impact the development of gender dysphoria in adolescence. Importantly, the rigid thinking that is characteristically observed in ASD children contributes to the persistence of their conviction that they are transgender. In turn, this may be mistakenly interpreted as confirming the original diagnosis of gender dysphoria introducing confirmatory bias.

Outcomes of transitioning: desisters, persisters and longer-term adjustment

There are two main strands of outcome research. The first concerns the trajectory of children who identify as transgender in terms of whether they pursue a medical pathway. The second addresses the longer-term outcomes after medical transitioning.

The data on the outcome for children who identify as transgender is limited because the expansion of referrals in this age group is still relatively recent. Most clinical research to date, both on nonmedical social transition and hormonal interventions, is based on individuals who are transgender in a binary fashion (i.e., sex assigned at birth male and identifying as female, or sex assigned at birth female and identifying as male). There is a relative paucity of information on gender diverse and gender nonbinary adolescents who do not identify as transgender in the binary sense. Research is needed to establish if and how these young people may differ.

Several studies have attempted to measure the percentage of prepubertal children with cross‐gender identification who will continue to identify as such in adolescence and adulthood (i.e., ‘persisters’) versus those who abandon this form of identification (i.e., ‘desisters’)². Nearly all of these studies have had methodological flaws. Several have included subthreshold cases of childhood gender dysphoria (Olson, 2016). The timing of the studies yields an interesting perspective: research carried out after the year 2000 when we can assume a comparatively more tolerant social environment and hence higher levels of referrals, estimate persistence rates of 12–39 percent (Drummond et al., 2008; Singh, 2012; Steensma, 2013b; Wallien & Cohen‐Kettenis, 2008) while those conducted before the year 2000 estimate lower persistence rates (between 2 and 9 percent) (Green, 1987; Zuger, 1984). Although there are clear differences depending on the time period in which the research to...

Table of contents

• Cover
• Half Title Page
• Series Page
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Acknowledgments
• Introduction: identity in modern times
• 1 Research perspectives on transgender
• 2 Understanding transgender: controversies and challenges
• 3 Arriving at the body
• 4 Trans-itory identities? Adolescent development, gender and identity
• 5 Towards a psychoanalytic ethics-based practice with transgender individuals
• Conclusion: keeping the body in mind
• Bibliography
• Index