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.