Will Malone MD

@jbvconnor For many, a fixed trans identity provides a rigid psychological structure that hides underlying uncertainty and doubt about who they are and where they fit in. They may believe that a trans identity is the solution to their underlying insecurities. It may also create an idealised avatar that promises, in effect: “If only I’d been born differently, I’d be much happier with myself and free of self-hatred.” Any invitation to think or explore the nature of this belief system can be experienced as a threat, causing psychological pain. The young person’s own doubts and confusion may be disowned and attributed to therapists or parents. Good therapy involves two stages: first, understanding the way the individual sees the world; then, helping them gain enough distance from that identification to become interested in other perspectives and ways of thinking about themselves. This means bringing their beliefs and the function they serve into view. The affirmation model can bypass this process by supporting the young person unreservedly without first bringing those beliefs and their function into view, or helping them consider other perspectives. In this way, there can be a collusion between the patient and the clinician. What remains unexamined is that the capacity to tolerate psychological turbulence is essential for psychological development. Therapeutic work requires experienced therapists who can support the individual over time, often working uncomfortably between two risks: on the one hand, pushing the patient to face reality in a way that may rupture the therapeutic relationship; on the other, avoiding the difficulty by becoming collusive and ineffective. In effect, the affirmation model exchanges short-term relief from doubt, confusion and uncertainty for security, leading to a psychic retreat from developmental opportunities. In this way, it protects both the patient and the clinician from the psychic pain and turbulence involved in exploring and thinking things through. Another problem is that these psychic defences flatten the capacity to experience pleasure as well as pain. Tragically, short-term solutions to psychic pain can have hidden long-term consequences. A symptom of this problem is clinical teams’ proud boasts that they knew the patient should transition because the young person was so certain. These boasts treat the young person’s certainty as a sign of health, rather than a red flag that they may be caught in a rigid belief system that exchanges thought for certainty. A more in-depth version of this argument is available in this open-access paper: onlinelibrary.wiley.com/shar… @CASCltd @rachelbaxendale @stellaomalley3