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: 

  1. 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. 
  2. 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.