A young trans woman whose gender dysphoria focuses on her height requests a surgery that would involve breaking her legs and removing four inches to render her shorter; a trans man wishes to become pregnant and bear a child – without this undermining his sense of masculinity; a being who refuses any form of gender identity asks for surgery in order to render them illegible to society; a person who has lived as a woman for 50 years asks for help in faking their own death, secretly undergoing transition and returning to their community in the guise of a distant male relative. These are all struggles that people have presented with at the NHS gender identity clinic at which I work, people requesting help in finding their own unique way of making life bearable. A large proportion of our patients are transitioning from one binary gender role to another and request a set of institutionally sanctioned medical interventions such as laser hair removal, hormone treatment or gender reassignment surgery; a standardised treatment pathway offers the promise of a relatively set trajectory through which the patient’s identity can be physically realised. However, the diversity of ways in which gender may be embodied and the variety of creative solutions to the problem of identity challenge the medical discourse that favours certainty, evidence-based practice and clear treatment pathways. In a clinic that offers gender-related medical interventions, it is a hotly contested and politically charged question of whether it is appropriate and ethical to offer a space where the trans person may, if they so choose, explore their gender identity by articulating their fantasies, desires and identifications through talking therapies. Increasingly detached from this debate, psychoanalysis finds itself falling from the stage on which the drama of gender unfolds, a passage à l’acte (Safouan, 2004) which apparently few will mourn. 

The normalising tendencies of psychotherapy, and perhaps particularly psychoanalysis, have not served the trans community. Unforgivable abuses have occurred, and continue to occur in some quarters, through which the trans subject’s subversion of the social laws that govern a person’s intelligibility and legitimacy are met with punishment and attempts at correction. Psychotherapists in the gender identity clinic are sometimes tasked with giving their opinion on whether a patient is suitable for hormone treatment or surgery referral, occupying the position of gate-keeper to medical treatments. This power dynamic can unsurprisingly create a degree of suspicion towards the therapist, which can lead the person to align their discourse with the dominant narratives of transgender legitimacy – such as that of “being born in the wrong body” – for fear of being refused treatment. Historically, some psychoanalysts have adopted the heteronormative assumption that a trans identity indicates a psychotic psychic structure (Millot, 1990): a lack of the capacity for symbolisation. This trend towards generalising in ways that undermine the subjectivity of the individual are unhelpful at best and undoubtedly often disastrous. Until fairly recently, it was not permissible for a gay man or lesbian woman to train as a psychoanalyst in Britain due to the belief that their sexuality was inherently pathological; this prejudice has never been adequately addressed in this country (Newbigin, 2015). It is an underdeveloped yet vital area of study and potential learning for psychoanalysis to identify and come to terms with its own complicity in heteronormative practices that have marginalised queer individuals, both as patients and would-be analysts. In avoiding responsibility, refusing to acknowledge guilt and disengaging from uncertainty, we fail our patients and ensure that psychoanalysis is left behind in the conversation on gender.