Ambivalent Body A Trans Relational Method Of Conceptualizing Gender Reassignment Surgery

Ambivalent Body:
A Trans*Relational Method of Conceptualizing Gender Reassignment Surgery
by
Kelsey A. Milano
Submitted in partial fulfillment of the requirements
for the degree of
Master of Arts in Counseling Psychology
Pacifica Graduate Institute
15 March 2022

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© 2022 Kelsey A. Milano
All rights reserved

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I certify that I have read this paper and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
product for the degree of Master of Arts in Counseling Psychology.
____________________________________
Kathee Miller, M.A., L.M.F.T.
Portfolio Thesis Advisor
On behalf of the thesis committee, I accept this paper as partial fulfillment of the
requirements for Master of Arts in Counseling Psychology.
____________________________________
Thomas Steffora, M.A., L.M.F.T.
Research Associate
On behalf of the Counseling Psychology program, I accept this paper as partial
fulfillment of the requirements for Master of Arts in Counseling Psychology.
____________________________________
Gioia Jacobson, M.A., L.M.F.T.
Director of Research

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Abstract
Ambivalent Body:
A Trans*Relational Method of Conceptualizing Gender Reassignment Surgery
by Kelsey A. Milano
Gender Reassignment Surgery (GRS) is an increasingly sought-after treatment amongst
trans* individuals. Mental-health professionals often stand between trans* patients’
need/desire and their attainment of such services. Utilizing a qualitative, hermeneutic
approach, this thesis examines the historical practices in working with this population to
understand current therapeutic perspectives. This research utilizes contemporary practices
and ideologies informed by relational psychoanalysis to illuminate how the therapeutic
process often engages in exactly the bifurcated treatment it ostensibly seeks to transcend.
After investigating the various “sides” on which clinicians and their trans* patients fall in
considering GRS, the futility of certainty and the unavoidable ambivalence become
clearer. The experiences of trans* clients are frequently pathologized, stigmatized, and
fetishized, and the question of GRS is situated between transphobia and affirmation. This
thesis proposes a therapeutic process that transcends this binary, and instead embraces a
toleration for ambiguity, fluidity, and confusion.

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Acknowledgments
Thank you to my friends, especially those of the trans* community, who have
expanded my ideas about humanity, love, and self-knowledge and for making me have
fun and making me laugh. Thank you to my cohort at Pacifica Graduate Institute for
consistently challenging me to question more and better. Thank you to Valley
Community Counseling Clinic for offering the intellectual discourse and rich analytic
community that has transformed and supported my own modest practice. And thank you
to my therapist, for helping me to hold what I do not know.

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Dedication
For Hannah and Hunter, the loves of my life.

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Table of Contents
Chapter I Introduction .................................................................................................1
Area of Interest........................................................................................................1
Guiding Purpose ......................................................................................................6
Rationale..................................................................................................................7
Methodology............................................................................................................9
Research Problem and Question..................................................................9
Methodology..............................................................................................10
Ethical Concerns....................................................................................................11
Overview of Thesis................................................................................................12
Chapter II Literature Review ......................................................................................13
Transsexuality and Sex Reassignment Surgery.....................................................13
From Transsexual to Transgender and the Question of Diagnosis.......................16
Current Therapeutic Attitudes and Gender Reassignment Surgery as a Cure.......20
Gatekeeping and Transphobia ...................................................................20
Informed Treatment and Affirmation........................................................21
Gender Reassignment Surgery ..................................................................24
Chapter III Findings and Clinical Applications ...........................................................28
Fear of Complicity as an Enactment of Gatekeeping............................................28
Knowing Ahead of Time (A Response to Informed Treatment)...........................32
GRS Beyond Solution: What If There If Nothing to Fix?.....................................36
Waiting ......................................................................................................37
Imagining...................................................................................................39
Mourning ...................................................................................................43
Clinical Applications.............................................................................................45
Chapter IV Summary and Conclusions........................................................................47
Summary................................................................................................................47
Conclusions ...........................................................................................................48
Clinical Implications and Future Research............................................................50
References .........................................................................................................................53

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Chapter I
Introduction
We are so accustomed to thinking of “otherness” as a radical difference of kind—
“other” as complete opposite—that we forget it might also be a difference of
degree—otherness subtly differentiated along a continuum of similarity. (Cowan,
2002, p. 114).
Area of Interest
Attempting to define the term transgender is an inherently paradoxical exercise.
In their social/medical research of transgender individuals, psychologists Charlotte Chuck
Tate et al. (2013) defined the prefix trans- as “across” or “beyond,” (p. 768), but because
the definition does not indicate a destination or arrival (an across or beyond to___?), it
resists fixity. Prolific transgender activist and writer Leslie Feinberg (1997) elucidated
the term transgender as “an umbrella term to include everyone who challenges the
boundaries of sex and gender,” (p. x), and for the purpose of this thesis, I use the
demarcation trans* to describe such individuals. The increasingly recognized boundary
of gender is the binary, defined by social workers Gary J. Jacobson et al. (2020) in their
book Sex, Sexuality, and Trans Identities, as “any phenomenon or system that’s
composed of two and only two parts,” meaning, in regard to gender, that “there are men,
and there are women,” (p. 8). So, to be nonbinary—one of the many gender expressions
and identifications under the transgender umbrella—is to inhabit a “third kind” of gender,
not unlike, as Jungian analyst Lyn Cowan (2002) mused, “a close encounter of the third

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kind . . . [involving] being ‘taken’ by something ‘alien,’ something as yet unconsidered”
(p. 104).
There are consequences of being, in Cowan’s (2002) words, something alien and
unconsidered, especially in a predominantly cisgender world. The prefix cis- or “on the
same side of,” which is used to denote “those individuals who . . . have a gender identity
that is the same label as their birth-assigned category” (Tate et al., 2013, p. 768), implies
that to be other, to be on a different side (or no side at all), could be an antagonism or a
threat.
In my own experience of gender questioning and desire for surgical intervention
via Top Surgery—reconstructive surgery performed on the chest usually involving a
variation on the double mastectomy—I arrived at a stalemate in my own psychotherapy
process as well as with the medical procedural process. I hoped that I would become
qualified for subsidization of Gender Reassignment Surgery (GRS) by my insurance
company, but as the process moved forward, I actually became less sure about my
decision. I realized that, regardless of insurance requirements, my desire for certainty was
also a consequence of binary gendered thinking. This is what led me to wonder: If
therapeutic strategies in working with trans* individuals considering GRS are presently
situated between transphobia and affirmation, how can a therapeutic process resist this
binary and instead embody a toleration for ambiguity, fluidity, and confusion?
I spoke with two trans* friends on the topics of invisibility and confusion in their
experiences of transitioning. Leading trans* researcher and psychoanalyst Avgi
Saketopoulou (2020) clarified that transitioning can include trans* individuals who “need
to surgically align their body with their self-identified gender,” as well as those who are

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“only altering social signifiers (e.g., name, pronouns) but uninterested in medical/surgical
procedures” (p. 1019). One trans* friend, in the latter category, who has an ambivalent
relationship to the idea of medical transition, shared that “to refuse to identify as either
woman or man is to suddenly become invisible to huge swaths of the population”
(personal communication, May 2021). This reflection substantiates the claims of alien
otherness (at least in the eyes of the majority, cisgender community) that Cowan (2002)
identified.
Another trans* friend, who had medically transitioned Female-to-Male (FtM),
spoke about an attitude that is not exclusive to cisgender individuals but held by society
at large: the intolerance of confusion. He discussed his process of transitioning and the
discomfort of being in-between, of being confusing to the people around him while
appearing as neither cis-female or cis-male. Psychoanalyst and social worker Griffin
Hansbury (2005) acknowledged this perspective of confusion in the mental health
community and reported that “therapists often experience their [trans*] patients as
confusing, disconcerting, demanding, deceiving, uncommunicative, self-mutilating, and
totally resistant to the transference” (p. 20). This contemporary observation is reminiscent
of psychoanalyst Daniel J. Gaztambide’s (2013) account of earlier psychoanalysts, such
as Sandor Ferenczi, who shifted toward a “psychotherapy for the people” (p. 155), and
the consideration that “what might be framed as the patient’s inability to engage in the
analytic process may, in fact, reflect the analyst’s inability to engage the patient” (p. 153).
In the same way that my trans* friends communicated their sense of society’s inability to
engage with them—or more specifically, engage with their trans*ness—it seems that
confusion, a symptom of not knowing, is the primary culprit for such obduracy.

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Psychoanalyst Michael Fordham (1993) argued that many beginning
psychotherapists “want to have a blueprint . . . which they can know beforehand and
apply” so that they “are spared the often quite severe bewilderment that the not knowing .
. . can evoke,” (p. 131). Psychoanalyst Nancy McWilliams (2004) similarly extrapolated
on this desire to be spared, qualifying the wish for “intellectual brilliance or sophisticated
social skills or mastery of the literature on technique” (p. 52) as an anxious defense
against the “almost intolerable experience” (Fordham, 1993, p. 133) of not knowing.
Fordham (1993) and McWilliams (2004) made these observations about psychotherapists
working with the average patient. Therefore, the prognosis for effective psychotherapy
with those “other” patients Gaztambide (2013) noted, like trans* patients, whose
“analyzability” depends on “the analyst’s difficulties and insecurities” (p. 153) seem
doomed to Hansbury’s (2005) premonition of “an atmosphere of suspicion and distrust”
(p. 20).
Trans* psychoanalysts like Sonny Nordmarken (2014) and Jack Pula (2015) have
shared insights that straddle the experiences of both clinician and patient in the space that
Nordmarken (2014) coined as “betweenness” (p. 38). Pula (2015) elaborated on the
different sides of gender and its polarizing effects on trans* and nontrans people alike:
the “angst [it] evokes,” and “the conflict it can spark within and between people,” and
“the potentially violent currents it carries and wields” (p. 814), as well as its potentiality
as “a creative, ingenious vehicle for relation, communication, affect, merger, boundary,
sharing, bonding, entering, and leaving” (p. 820). The radicality of Pula’s remarks on
gender lies in the fact that so many aspects exist all at once, reflecting the core

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component of trans* itself: “that there are more ways to look at gender than either/or”
(Jacobson et al., 2020, p. 8).
Another imperative qualification of Pula’s (2015) conceptualization of gender is
that of a relational vehicle, evoking the central tenets of relational psychoanalysis,
defined by psychoanalyst Max Belkin (2020) as “an open-ended search for understanding
each participant’s experience of difference that eschews certainty, embraces ambiguity . .
. [and] acknowledges that one’s understanding of one’s self and the other are always
ongoing and elusive, enriching and transformative” (pp. 14-15). In other words, if gender
is less of a concrete identification (Gozlan 2018) and more of a movement of self,
relational psychoanalysis mirrors its fluidity and intersubejecivity. Nordmarken’s (2014)
depiction of trans*ness as “a tool of resistance and reconnection that can help us build
connections across difference,” echoes Jessica Benjamin (2009)—a lead researcher on
relational psychoanalysis—and her emphasis on “rupture and repair” at “the heart of the
moral third” (p. 442). Benjamin went on to describe this third space between clinician
and patient as “the courage for non-judgmental awareness that honestly recognizes
moments of dissociation, misattunement, [and] defensiveness,” and as essential for “both
participants in the analytic dyad [to] survive . . . the other’s failure” (p. 442).
Jacobson et al. (2020) confidently stated that “binaries collapse in the face of the
provable existence of a third component” (p. 8), and if trans*ness represents, as Cowan
(2002) suggested, a third gender, then the third space of processing outlined by Benjamin
(2009) and other contemporary psychoanalysts like Thomas Ogden (1994) may alleviate
the binary positioning of therapist and patient. This positioning is especially evident in
the process through which trans* patients seek medical/surgical intervention, where they

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must demonstrate their eligibility for such services by exhibiting symptoms of gender
dysphoria according to the most current edition of the Diagnostic and Statistical Manual
of Mental Disorders (American Psychiatric Association [APA], 2013) paving the way for
therapists to be the decision-makers of trans* patients’ treatment (Schulz, 2018).
Guiding Purpose
The guiding purpose of this thesis, like the topic at hand, is manifold, but
primarily consists of the following: to explore mental health professionals’ attitudes
towards adult trans* individuals over the past century in order to locate their
circumstances in the present moment; to identify the ways in which the treatment of
trans* individuals, specifically as it relates to receiving medical/surgical services, has
imitated the binary system that they desire to escape; and to offer contemporary relational
psychoanalytic perspectives on the treatment of trans* individuals in their pursuit of
medical/surgical intervention that may circumvent such binary models of treatment. For
the purpose of this thesis, the subject of my focus is trans* individuals of adult age, as the
subject of medical services for adolescents is a separate area of research with different
implications and consequences.
Psychoanalyst Sheila L. Cavanagh (2018) asserted that “analysts must
acknowledge and account for their anti-trans* sentiments in order to work with trans*
clients” (p. 91), but most therapists do not understand that simply working within the
existing system of treatment may, in and of itself, be anti-trans*. This type of
consideration requires what ethicist David Ross Fryer (2015) delineated in his book
Thinking Queerly as a posthumanist perspective, which “[calls] into question those very
assumptions that we bring to the table,” asking theorists and practitioners to “step out of

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the natural attitude into a state in which they may keep their assumptions suspended and
inquire into the very root of the question” (p. 10). Applying this perspective to the trans*
experience, psychoanalyst Thomas Olver (2019) exhorted a “return to investigating the
ontogenesis of gender, perhaps by thinking of gender itself as a disorder” (p. 25). This is
a radically different point of view on the trans* experience than has been held by mental
health practitioners for most of the last century. The traditional questions ask why
someone is trans* and how to treat or cure them, rather than “‘how is someone trans?’
(What form their trans-ness takes, how they inhabit it, etc.)’” (Hansbury, 2017 as cited in
Saketopoulou, 2020, p. 1020). Thus, this thesis examines how the treatment of trans*
individuals seeking medical/surgical services came to exist as it does now, and how
psychotherapists may hold the experiences of their trans* patients differently.
Rationale
As previously mentioned, a fundamental point of suffering for trans* patients in
their day-to-day experiences, as well as in their efforts to enter psychotherapy and pursue
medical/surgical transition services, is the intolerance for confusion. Cavanagh (2018)
denounced the diagnostic and therapeutic processes practiced by clinicians today as “a
refusal to deal with trans* sexual difference” (p. 91), making it very clear, in this context,
that the diagnosis most trans* patients receive is “unnecessarily pathologizing” (Schulz,
2018) and is not actually dealing with trans* individuals. Rather, these processes are
attempting to “‘fix’ a patient’s gender” or “predict whether the patient will regret changes
made in their body” (Saketopoulou, p. 1022. These attempts demonstrate McWilliams’s
(2004) observation on amateur therapists and their desire to “attribute difficulties and
failures in therapy to the limitations of an external technique or to the inappropriate

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matching of technique to client” (p. 66). The failures McWilliams described parallel
Benjamin’s (2009) reconceptualization of failure as “essential to extricating oneself from
the reciprocal bedrock of complementary relations [in which] . . . only one reality can
prevail” (p. 442).
In her book Shadow of the Other, Benjamin (1998) established a root aspect of
relational analysis as “a reversal that restores the analyst’s subjectivity as a fallible being
and the analysand's subjectivity as one who can know and speak with authority” (p. xii)
and thus presented an answer to Saketopoulou’s (2020) question for clinicians working
with trans* individuals: “How willing are analysts to cede the privilege that comes with
occupying positions that permit their politics to be understood as ‘reality’ or ‘fact’?”
(p. 1021). By relinquishing authority, admitting to not knowing, and submitting to
confusion therapists and their trans* patients may, as Benjamin (1998) ascertained, be
able to “[contemplate] the difficulty of creating or discovering the space in which it is
possible for either subject to recognize the difference of the other” (p. xii). In this space
“an important sign of re-opening thirdness is being restored to the capacity to hear
multiple voices” (Benjamin, 2009, p. 442), emulating the trans* movement beyond the
binary into the “polynary” where “[gender] components are not locked in perpetual head-
to-head struggle” (Jacobson et al., 2020, p. 8).
For trans* individuals, who, in Nordmarken’s (2014) perceptions, are often
perceived as “monstrous” or embodying “terrifying otherness” (p. 40), a relational
treatment has incredible implications for not only unravelling the “oppressive, archaic,
and redundant” (Olver, 2019) modalities of working with trans* patients and their desire
to pursue surgical/medical services, but also for other Others, who are “by definition, a

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definitional inferiorization” (Nordmarken, 2014, p. 40), and who are more susceptible to
re-enactments of power dynamics, misattunement, or cultural/socioeconomic biases in
the therapeutic setting (Gaztambide, 2014).
Methodology
Research Problem and Question
Trans* individuals face a range of challenges when considering treatment options,
and mental health professionals offer a spectrum of treatment. Laine Hughes (2018),
doctoral candidate in gender, feminist and women’s Studies at York University crafted
the Wrong-Body Narrative as a tool for trans* patients to navigate the extensive
assessment requirements to receive transition-related medical services. According to
Hughes, the function of the Wrong-Body Narrative for trans* individuals is to provide a
convincing argument for transition amidst the “phobic, clinical distrust of trans people”
(p. 185), in that clinicians may refuse access to service for “those deemed inauthentic,
whose experiences were not painful enough, not ‘wrong’ enough to justify intervention,”
(p. 184). This method of treating trans* individuals who desire surgical intervention is an
example of the far end of the binary spectrum of trans* treatment: that which emphasizes
dysphoria or “wrong-bodiedness” (p. 189).
On the other side of the spectrum of trans* treatment is that of affirmation,
outlined in A Clinician’s Guide to Gender-Affirming Care by Sand C. Chang, a
psychologist, Annaliese A. Singh, a professor and associate dean of diversity, equity, and
inclusion, and lore m. dickey (2019), a behavioral health consultant, as “client-centered”
with “an inclusive, non-binary view of gender” (p. 2). Although this framework supports
trans* patients’ “self-determination and autonomy,” the risk of affirmation, as posited by

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psychiatrist and psychoanalyst David Bell (2020), is the “alignment with affirmative
lobbies . . . that seek to ‘affirm’ the wish change gender, tending to see it only as a
positive choice to be encouraged” (p. 1033). Moreover, Bell conjectured that the
upholding of affirmation as a panacea can create a “paranoid universe” where to question
a trans* patient’s experience of dysphoria is seen “as an expression of ‘transphobia’”
(p. 1036).
These treatment examples, asking trans* patients for a stark commitment to
gender incongruence (dysphoria/pathologizing) or gender affirmation (“the celebratory
transgender euphoria that has become so popular in recent years” [Howsepian, 2019,
p. 64]), are opposite sides of the treatment spectrum, but concretize the problem of the
binarity of the spectrum, nonetheless. The gap in research that I recognized was the space
between these sides of the treatment spectrum, leading me to seek research in advocacy
of a less binary treatment. Thus, my research question is: Since therapeutic strategies for
trans* individuals considering Gender Reassignment Surgery (GRS) are presently
situated between pathology and affirmation, how can a relational, psychoanalytic process
of therapy dismantle this binary, and instead embody a toleration for ambiguity, fluidity,
and confusion?
Methodology
For this thesis I employed a hermeneutic, qualitative methodology in that I
“[analyzed] texts to extract central themes,” and to “form connections” (Pacifica
Graduate Institute, 2020, p. 45) between the Research Problem (the inherently binary
posture of therapeutic practice for trans* patients) and potential responses to that problem
(theories of relational analysis that invite new conceptions of “thirdness,” “otherness,”

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and “confusion”). Of course, I cannot propose a conclusive answer to this problem. I am
more interested in asking questions and investigating the ways in which contemporary
psychoanalytic theories and practices are already, and will hopefully continue to,
intersect with the available research on the problem.
I utilized the grounded theory qualitative approach, which “seeks a general
explanation…of a process,” (Creswell, 2015, p. 550)—in this case, the process of
exploring at treatment options for trans* individuals—to thoroughly examine the
research and identify theoretical themes to support my hypothesis and/or expand the
perspective with which this problem is viewed. One limitation of this methodology is that
the research available on the clinical treatment of trans* individuals subscribes to the
attitudes I sought to criticize. However, I attempted to review a wide range of
perspectives.
Ethical Concerns
This thesis calls into question the lynchpin of clinical psychological diagnosis and
treatment—the DSM-5 (APA. 2013) and the history of gender dysphoria—as well as the
most progressive, evidence-based consideration on treatment of LBTQIA individuals—
affirmative therapy— without positing any specific, alternative modality or solution to the
gaps in efficacy that these cornerstones promise.
I take a posthumanist (Fryer, 2015) position in writing this thesis, in that I do not
claim a humanistic opinion, which involves advocating for “a core set of qualities that all
humans must possess or embody in order to be considered human” (p. 10), toward the
trans* experience. I also do not put forth an anti-humanist position; “a reactionary
position” that “criticizes humanism’s myopic universalism” (p. 8) and decries the

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contemporary modalities of treatment for trans* patients in totality while attempting to
formulate a better method of treatment. Rather, I hope to qualitatively examine the
modalities that exist and question them with the guidance of contemporary
psychoanalytic reports to invite curiosity and potentiality for a less binary, more
expansive therapeutic approach to working with trans* patients and beyond.
Overview of Thesis
Chapter II begins with a modest history of the treatment of trans* individuals in
the psycho-medical field over the last century to provide a foundational understanding for
the development of trans* related diagnoses in the DSM-5 (APA. 2013). The evolution of
these diagnoses, from the earliest conceptions of trans-sexuality to the contemporary
definition of gender dysphoria, is then explored from the perspectives of both clinicians
and trans* patients. The final section of this chapter reviews the landmarks of
contemporary treatment with trans* patients that are then questioned in Chapter III,
including the Informed Consent Model as a reaction to clinical gatekeeping, affirmation
as an alternative to pathologizing, and the polarized views on Gender Reassignment
Surgery as an effective solution for trans* patients. Chapter IV offers conclusions as well
as clinical implications and ideas for further research.

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Chapter II:
Literature Review
This chapter reviews the historical treatment of trans* patients and how mental
health professionals’ attitudes toward GRS have evolved. The first section provides an
overview of the history of attitudes toward, theories regarding, and approaches in
working with trans* individuals, including the earliest practices of GRS. The second
section evaluates the evolution of diagnoses in working with trans* individuals and the
consequential controversial opinions. Finally, the third section details the most
contemporary stances by mental health professionals in their treatment of trans*
individuals and the implications of these positions in the administration of GRS to trans*
patients.
Transsexuality and Sex Reassignment Surgery
Researchers have examined how psychologists historically classified gender in
recent years. In 2012, psychiatrist Jack Drescher et al. catalogued the history of gender
classification. Drescher (2015) revisited this history and incorporated the most recent
developments in the DSM-5, which are presented in a later section.
According to Drescher et al. (2012), in 1886 German psychiatrist Richard von
Krafft-Ebing was the first professional to “document cases of individuals who desired to
live as members of the other sex,” and he deemed these cases “psychopathological”
(p. 568). The term to define such individuals, transsexualismus, was introduced in 1923
by German physician and sexologist Magnus Hirschfeld (Gozlan, 2018) as a distinction

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from homosexuality (Drescher, 2015; Drescher et al, 2012; Gherovici, 2018); and in
1949, sexologist David Oliver Cauldwell introduced the English term transsexual to
“refer to individuals wishing to become members of the sex to which they do not
belong,” (Gozlan, 2018, p. 2). Sexologist Harry Benjamin was the figure most
responsible for the popularization of transsexuality as a term and a concept in the 1950s,
particularly for his emphasis on “the biological aspect of transsexualism” (Gherovici,
2018, p. 81) and his advocacy for surgical intervention.
Benjamin’s work was thrust into the public spotlight by Christine Jorgensen, who,
as a male World War II veteran named George Jorgensen, left the United States to
receive a series of surgeries in Europe and returned physically transformed as a female in
1952 (Drescher, 2015; Drescher et. al, 2012). Although Sex-Reassignment-Surgery
(SRS) had been practiced by physicians in Europe since the 1920s, Jorgensen’s
demonstration of its potentialities precipitated the “awareness of the concepts of gender
identity, and later of experienced gender, as well as recognition of an increasing number
of people wishing to ‘cross over’ from their birth-assigned sex to another” (Drescher et
al., 2012, p. 569). Jorgensen’s successful surgery also increased the debate amongst
mental health practitioners about the value of SRS as an effective treatment for
transsexuals (Drescher, 2015).
Gherovici (2018) divided this debate between the ideologies of Cauldwell and
Benjamin. Cauldwell advocated for psychotherapy and cautioned against SRS because it
could never really change a person’s sex, whereas Benjamin advocated for SRS and
against psychotherapy because it “did not lessen the wish to change sex but rather forced
patients to hide their desire and therefore live miserable lives” (as cited in Gherovici,

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2018, p. 80). The practitioners in Cauldwell’s camp feared that SRS “foreclosed a
consideration of what may not be fully anatomical, as if the seeming efficacy of the
interventions on the organism would preclude any consideration of other issues involved
in the transition of sex” (Gherovici, 2018, p. 81), such as “a severe neurotic or a
psychotic, delusional condition in need of psychotherapy and ‘reality testing,’” (Drescher
et al., 2012, p. 569).
In the 1960s, leading gender researcher and psychiatrist Robert J. Stoller bridged
the polarizing views of Benjamin and Cauldwell and “moved away from a biological
model to a psychological one,” while defending SRS as a viable option “for patients
properly diagnosed as transsexual” (Gherovici, 2018, p. 81). Stoller’s theory of primary
transsexuality versus secondary transsexuality led to criteria for a “proper diagnosis”
(Withers, 2015). While Cauldwell and Benjamin stood on opposite sides of
psychotherapy versus surgery for the treatment of transsexuals, Stoller (1968) went one
step further in recommending psychotherapy or surgery depending on this primary or
secondary categorization. Primary transsexuals demonstrated the “process of
conditioning and imprinting from mother to infant that predates symbolization” and were
thus “not amenable to analysis” but “were likely to benefit from surgery” (Withers, 2015,
p. 396). Secondary transsexuals, on the other hand, became so as a result of “a variety of
sources,” including “psychotic delusions, homosexuality, transvestism, paraphilias and
neurotic conflicts around gender identity,” and “were likely to be harmed by [surgery],”
(p. 396).
With these distinctions in mind, Stoller (1968), in his seminal book, Sex and
Gender: On the Development of Masculinity and Femininity, warned of the

16
“[implications] that anyone making such a request is a transsexual” and the
“[oversimplification] . . . in gender identity,” (p. 247); he also argued in support of SRS
in the treatment of transsexual patients, that “everything should be done to assist them in
passing,” (p. 279). Nevertheless, Benjamin’s commitment to transsexualism as a
biological problem and SRS as a curative solution to distress—at least more so than
psychotherapy or psychoanalysis —“created a protocol for sex change in which
psychiatrists were given the power to determine who would be potential candidates for
surgery,” (Gherovici, 2018, p. 80), and therefore also exacerbated questions of patient
qualification as it related to pathology and diagnosis.
From Transsexual to Transgender and the Question of Diagnosis
Shifting conceptualizations of transsexualism in psychology are reflected in the
DSM. Trans-sexualism first appeared in the DSM-II in 1968, under the parent diagnosis
category “Sexual Deviations” and was then revised in 1980 in the DSM-III as a
“Psychosexual disorder” (Drescher, 2015, p. 387). In 1987, in the DSM-III-R, trans-
sexualism was moved to “Disorders Usually First Evident in Infancy, Childhood, or
Adolescence,” along with Gender Identity Disorder (GID) of adolescence, non-
transsexual type (p. 387). Currently, GID has eclipsed transsexualism completely under
the parent category Gender Dysphoria (GD) in the DSM-5 (p. 387) and is defined by
psychologist Antonio Prunas et al. (2017) as “a marked incongruence between the
individual’s expressed/experienced gender and the gender assigned at birth, causing
clinically significant distress or impairment in social, occupational, or other important
areas of everyday functioning” (p. 1306).

17
Bell (2020) asserted the importance of distinguishing GD, the diagnosis (“deep
feelings of discomfort with the sexual body that has multiple sources and multiple
appropriate therapeutic approaches” [p. 1031]) from transgender, the identification
(“those individuals who have completed or are embarking upon medical and surgical
interventions aimed at altering their gender identity” [p. 1031]). Although Bell’s effort to
separate identification and diagnosis aligns with the “movement towards depathologizing
gender variance” (Gherovici, 2017, p. 21), the effort is complicated by the fact that these
definitions of transgender and dysphoria are not universally accepted in the trans*
community. Transgender, as mentioned in the introduction, seems at the very least to
indisputably and ubiquitously include any gender expression outside of the traditional
gender binary (Drescher, 2015; Gherovici 2017; Jacobson et al., 2020). This conception
of transgender subsumes the term transsexual (Drescher, 2015) with the delineation that
transsexual persons have an investment in attainment of physical changes (Gozlan, 2018),
whereas transgender persons do not. This contrasts Bell’s (2020) previous assertion that
to be transgender is to desire medical/surgical intervention.
Psychologists Lyn Carroll and Paula J. Gilroy (2002) argued that trans* patients
do not necessarily “want to alter their bodies surgically and hormonally,” nor “identify
with the feeling of being ‘imprisoned’ or ‘trapped in the wrong body’” (p. 234). This
discernment, first marked by Stoller’s (1968) suggestion that “those aspects of sexuality
that are called gender are primarily culturally determined; that is, learned postnatally”
(p. xi), is a stark departure from Benjamin’s (1966) conviction that “since . . . the mind of
the transsexual cannot be adjusted to the body, it is logical and justifiable to attempt the
opposite, to adjust the body to the mind” (as cited in Hansbury, 2005, p. 19). The

18
proposal of gender as separate from sex and influenced by “a psychological sense of self
that is informed by a sociocultural context . . . and . . . a set of expectations that
individuals use to interact with one another” (Tate et al., 2013, p. 767) is part of the
greater shift toward transgender as an umbrella term amongst mental health professionals
in the effort to be “non-medical and subsequently nonpathologizing” (Drescher, 2015,
p. 390).
However, mental health professionals continued to grapple with appropriate
definitions. Hansbury (2005) recognized that “[trans*] patients have in common the
compelling need to resolve a contradiction between their physical sex and psychic
gender” and, like Bell, offered that this “contradiction . . . is oftentimes best resolves
through some degree of physical change” (p. 19). This “compelling need” is synonymous
with the feeling of incongruence mentioned by Prunas et al. (2017) and Olver (2019),
who asked, “What exactly is it that one feels incongruent to?” (p. 19).
The American Psychiatric Association (APA) (2013) specified that there can be
“incongruence between one’s experienced and expressed gender and one’s assigned or
natal gender,” (p. 822 as cited in Howsepian, 2019, p. 59). Olver (2019) argued that this
definition from the APA locates gender “at a somatic level, focused on but not limited to
the genitalia and secondary sex characteristics,” (p. 10). Olver’s argument recalls earlier
conceptions of the term transgender, particularly Stoller’s ideas of primary and
secondary transsexuality, which social worker Miriam N. Oles (1977) had further
simplified into those who embody “true transsexualism” versus those who are “intensely
uncomfortable in their anatomical gender” (p. 68). Psychologist David Pilgrim (2018)
ventured that this bifurcation of experience contributes to an “hierarchy of

19
epistemological privilege” (p. 317) within the trans* community when they are striving to
be anti-hierarchical, non-binary persons (Jacobson et al., 2020).
Olver (2019) argued against the idea of intervention at the anatomical level if the
goal of intervention was “ideological congruence, that is, closer conformity of the
subject’s constructedness with the ideological paradigm” (p. 18) where the paradigm is
that of binary gender determined by genitalia. Hughes (2018) elaborated further on
ideological conformity with his description of the “Wrong-Body-Narrative” (p. 181),
which is adopted and utilized by trans* persons seeking surgery to assert “that they were
born with an incongruous psychological gender and physical sex” or, more simply, “born
in a body that is incorrectly sexed” (p. 182). Although the shift in the DSM-5 (APA,
2013) from the diagnostic labels of GID to GD was an effort to destigmatize and
depathologize the trans* experience (Gherovici, 2018; Hughes, 2018), social worker Barb
J. Burdge (2007) bluntly stated the predicament of “transgendered people desiring
surgical interventions” is an endeavour “dependent on being labelled with this
diagnosis—one built on gender stereotypes” (p. 247).
Psychiatrist Avak A. Howsepian (2019) elucidated on the fallacious premise of
GD as a disorder in his proclamation that “dysphoria is not the ‘problem.’ Rather, the
mismatch is the problem, and dysphoria is . . . a relatively healthy way in which one
detects this mismatch” (p. 62). Thus, “in the gender context, no amount of dysphoria that
is intrinsic, or internal, to one’s gender-related concerns can, by itself, result in Gender
Dysphoria’s being a mental disorder” (p. 61). This objection to the labelling of disorder is
sustained by many in the trans* community (Withers, 2015), which puts trans* patients
seeking Gender Reassignment Surgery (GRS; formerly Sex Reassignment Surgery or

20
SRS) in the uncomfortably paradoxical position of having to acquiesce to pathology.
From this pathological vantage point, GRS became less aligned with expression or choice
and more synonymous with curative promise.
Current Therapeutic Attitudes and Gender Reassignment Surgery as a Cure
Gatekeeping and Transphobia
This paradox—that trans* patients’ eligibility for gender transition services
depended on a GD diagnosis— was named by sociologist Elroi J. Windsor (2018) as
“psychomedical gatekeeping” (p. 134). Schultz (2018), in her probe into alternatives to
GD diagnosis in the treatment of trans* individuals, also noticed this “‘gatekeeping’
model” (p. 73). Windsor (2018) traced the model to the previously mentioned
medicalization of transsexuality in the early mid-20th century and the aspiration by
psychomedical professionals to “align the body with the mind” (p. 132). This placed
these professionals at a threshold founded on Benjamin’s elevation of psychomedical
practitioners as the ultimate decision-makers for treatment (Gherovici, 2018).
One fundamental concern of the gatekeeping model is, as psychoanalysts Mairéad
Losty and John O’Connor (2018) realized in their work with patients of “the non-binary
gender identity” (p. 40), that the theoretical premises of much psychoanalytic and
psychotherapeutic work “perpetuated a disorder-oriented conceptualization of gender
variance” (p. 41). This foundation has contributed to the “discomfort with a patient’s
ambiguities and contradictions” (Hansbury, 2005, p. 21). This is felt by many
psychotherapists, and as a result, the psychotherapeutic container may imitate trans*
patients’ painful experiences of misunderstanding and discrimination in society (Losty &
O’Connor, 2018).

21
Despite these concerns, if or when a trans* patient enters psychotherapy to gain
necessary approval for GRS, they are entering into a pathologizing and binary assessment
process where their authentic trans*ness is determined by an external party (Hughes,
2018; Gozlan, 2018; Windsor, 2018). Carroll and Gilroy (2002) argued that this process
of assessment and determination usually risks the communication of “‘either-or’
messages about sex reassignment surgery” (p. 233), which pressures patients to align
with binary gender norms by choosing one or the other. According to Windsor’s (2018)
research on how trans* patients’ gain approval from therapists for surgery, many patients
have “navigated therapy to get the letter that would authorize medical transition—the
‘golden ticket’—or bypassed that process in accessing hormones and surgeries” (p. 131)
by adopting symptomology like the Wrong-Body Narrative (Hughes, 2018) or other
learned behaviors from diagnostic literature (Windsor, 2018). This movement toward
bypassing the therapeutic process, or using it as a perfunctory means to a surgical end,
solidifies therapists in “a complex and potentially controversial role as the specialist
authorizing or vetoing the transition” (Gherovici, 2017, p. 20), as well as over-
emphasizes the presurgical process to the extent that post-surgical treatment, aftercare,
and processing can be neglected (Gherovici, 2017; Hansbury 2005; Hughes, 2018).
Informed Treatment and Affirmation
To combat the issues presented by gatekeeping practices, mental health
practitioners have sought to offer other solutions to support trans* patients as they
consider surgery. The Informed Consent model, introduced by the World Professional
Association for Transgender Health (WPATH) in 2011, (Levine, 2019; Olver, 2019;
Schulz, 2018) provides questions for mental health practitioners to review with their

22
patients before moving forward with surgery, including the patients’ hopes for the future
and their understanding of risks. Mental health practitioners are also strongly encouraged
to contemplate their patients’ cases based on existing research, literature, and clinical
experience (Levine, 2019). Schulz’s (2018) interest in alternatives to a GD diagnosis
manifested in an exploration of the Informed Consent Model, “which allows for clients
who are transgender to access hormone treatments and surgical interventions without
undergoing mental health evaluation or referral from a mental health specialist” (p. 72).
This interest was mirrored by psychiatrist Stephen B. Levine (2019), who corroborated
the gatekeeping schema and identified a need for a shift in practice that reflects the
evolution of trans* understanding from that of pathology to “an increasingly common
normal variation of gender identity development” (p. 219). He agreed that the Informed
Consent Model counters the gatekeeping model and diagnostic controversy in that “it
[asserts] that patients know best what they need to be happy” and “that there is nothing
pathological about any state of gender expression” (p. 220).
Carroll and Gilroy (2002) wrote extensively on the available resources for mental
health practitioners to become more informed about their trans* patients, including the
consumption of trans* literature, engagement with trans* individuals through panels or
interviews, field trips, and general familiarization with the socio-political history of the
trans* movement. This attention to education has been a significant shift over the past
decade (Levine, 2019), however, this educational focus neglects the therapist’s
exploration of their own subjectivity in the therapeutic field. The more pivotal concern is
the way in which mental health practitioners “may not only have a role in alleviating the
emotional distress of clients who challenge the binary gender system but may also be

23
responsible for contributing to or exacerbating it” (Carroll et al., 2002, p. 133). Hansbury
(2005) went so far as to declare that “the greatest barrier standing between the analyst
and the transsexual patient is the clinician's unrecognized negative countertransference”
(p. 21). This effort for clinicians and trans* patients alike to be “informed,” is a part of a
greater movement toward a trans-positive, or trans-affirmative, attitude (Carrol et al.,
2002), ostensibly placing trans* patients’ agency upstage of their professional mental
healthcare providers.
But what, exactly, is being affirmed in this effort to educate people? Olver (2019)
argued, in similar fashion to his critique of trans* incongruence, that to be gender-
affirming “implicitly and explicitly also affirms the ideology of gender,” as well as
“confirms the belief that gender is a real or true thing that can be objectively achieved”
(pp. 22-23). Bell (2020) agreed that affirmation represents “an ideological support for this
simplification” (p. 1033). Further, although Bell did not explicitly scrutinize Informed
Consent—a patient’s increased or expanded understanding of the consequences of
GRS—he questioned what it seeks to achieve, arguing that for mental health
professionals “fears of being called ‘transphobic’ close down space for thought, doubt
and exploration” (p. 1032).
Levine (2019), in outlining the types of GRS-related questions a clinician may
want to discuss with trans* patients, qualified that “the more these questions are refined,
the more limited knowledge becomes” (p. 222). With this statement, he inadvertently
admitted that the Informed Consent model’s effort to know about the patient’s present
experience may be bound by what is conscious, which illustrates Bell’s (2020) primary
point of concern that “many services lack any understanding of, and are overtly hostile to,

24
any thought about the unconscious issues” (p. 1033). Complementing Bell’s
apprehension of the mental health community’s “intolerance of doubt and thought”
(p.1036), Withers (2015) concurred that “surely, it is the psychoanalyst’s . . .
responsibility to attempt to work through these issues with the patient?” (p. 401). If, over
the past two decades, the treatment of trans* patients has evolved from a pathological,
dysphoria-centered point of view to “include the possibility of affirming a unique
transgender identity” (Bockting, 1997 as cited in Carroll et al., 2002, p. 133), the question
remains of the conceivability of GRS as neither a complete condemnation of one
embodied gender nor a complete affirmation of another.
Gender Reassignment Surgery
Benjamin’s understanding of trans* individuals’ experiences was as “a biological
error that could be corrected with somatic care” (Rosqvist et al., 2014, p. 21)—in other
words, an error that could be corrected by GRS. However, Stoller (1968) invited
inspection of this idea of correction, positing “that many are better adjusted . . .
postoperatively than they were before, is a conjecture that can be proven only by having
seen transsexuals . . . in intensive follow-up for months to years after they have
completed their sex-transformation procedures” (p. 247). Here, Stoller not only called for
greater caution and consideration in administering GRS to trans* patients, but also for
more scientific research into the subject (Withers, 2015).
More research has been done since the mid-20th century, but the results are
anything but conclusive. Some studies report significant post-operative life improvement
(Lawrence, 2003), however a more recent study in Sweden found that although surgery
helped to relieve gender dysphoria, it was less helpful with overall morbidity and

25
mortality rates (Dhejne et al., 2011). Another recent study found that GRS produced
equally reduced and increased levels of morbidity in its subjects (Simonsen et al., 2016);
all of which suggests that GRS is not a curative catch-all. The inconsistency of this
research demonstrates the need for more studies, but it more significantly indicates that
“post-surgical transsexuals are a risk group that need long-term psychiatric and somatic
follow-up” (Dhejne et al., 2011, p. 7). Indeed, the preoccupation with gender dysphoria
and GRS in the psychotherapeutic setting has been an occupational hazard for mental
health professionals for decades. Patients can suffer from this as well. Oles (1977) noted
that “the client may devote a tremendous amount of attention and energy to it, to the
exclusion of other aspects of his or her life. There is sometimes a tendency to defer other
goals and problems until ‘after the operation’” (p. 71).
Mental health practitioners with clinical experience working with trans*
individuals acknowledge the immense benefits for these individuals when accessing
medical interventions (Hansbury, 2005; Hughes, 2018; Prunas et al., 2017), but Hansbury
(2005) cautioned that it is “not a panacea” (p. 22). He continued, “Both social and
intrapsychic distress may continue throughout and after transition, for even after the
physical changes have been completed, contradictions persist” (p. 22). This is a far more
equitable assessment of the treatment of trans* individuals seeking GRS than Stoller’s
(1968) grievance “that no matter what one does-including nothing-it will be wrong”
(p. 247). A sentiment of incurability, of resignation to dissatisfaction (Stoller, 1968),
echoes throughout both statements. This signals the need for a perceptual shift in
considering the problem with trans* individuals, from what the problem is to is there a
problem? Moreover, can it be fixed?

26
Gherovici (2018) argued, “Since gender incongruence is not in itself a pathology,
sex realignment should not be considered a cure or a treatment” (p. 21). Pilgrim (2018)
questioned the casting of trans* individuals in the patient role to begin with, clarifying
that “there is no physical abnormality to correct” nor is “being trans . . . a psychological
abnormality” (p. 37). The perpetuation of trans* individuals as abnormal—be it through
the Wrong-Body Narrative (Hughes, 2018), claims of incongruence (Olver, 2019), or
claims of authenticity (Gozlan, 2018)—reinforces the binarity of normalcy and locates
GRS as a vehicle to cross from one side to another. Hughes contended that “medical
treatment that is intended to alleviate the distress associated with being trans . . . cannot
be exclusively attached to a notion of surgically repairing a wrong body, and in so doing,
‘curing’ trans people” (2018, p. 189). Hughes, speaking with the same candour as Stoller
and Hansbury, proclaimed that “regardless of what procedures one may undergo, flight
from the body one was born with is never fully possible” (p. 187).
So, if, as Hughes offered, “such bodily cohesion is nothing more than a very
popular fantasy, demonstrative of a universal longing for self-certainty that can never be
realized” (p. 190), and even GRS cannot achieve this impossibility, then the question
becomes, what is possible? If a fixation on knowing, certainty, rightness, and complete
transformation are abandoned, what can be fantasized, realized, or learned in the process
of contemplating and receiving GRS? The following chapter details the experiences,
discoveries, and theories of contemporary psychoanalysts who are exploring these
possibilities.

27
Chapter III
Findings and Clinical Applications
Saketopoulou (2020) identified three major points of countertransference in
clinicians working with trans* patients who were interested in GRS: (a) “The analyst who
works to ‘fix’ a patient’s gender because gender = sex = bedrock,” (b) “The analyst who
tries to predict whether the patient will regret changes made in their body,” and (c) “The
analyst who worries about becoming ‘complicit’ with the patient’s decisions regarding
hormono-surgical interventions” (p. 1022). I expound on these points by relating their
traits to the sections outlined in Chapter II. I argue that gatekeeping is a symptom of the
fear of complicity and Informed Consent and affirmation are treatments to circumvent
regret. Finally, I argue for the need to unravel GRS from the outcome of a fix or solution.
By relying on clinicians, writers, and theorists who were influenced by contemporary
relation analysis and gender theory, I demonstrate the ways in which the attitudes and
treatments described in Chapter II reinforce a binary psychotherapeutic experience for
trans* patients, and the perspectives and practices that are attempting to transcend this
binary.
Fear of Complicity as an Enactment of Gatekeeping
A therapist’s fear of complicity is directly related to the illusion that they are in a
position of power or control over the course of treatment for their trans* patients, which
is exactly how the gatekeeping model of administering surgical services has come to be.
As mentioned in Chapter II, an imperative step in this decision-making process is that of

28
diagnosis (Gherovici 2017; Gherovici, 2018; Levine, 2019; Schulz, 2018; Withers, 2015),
and the determination of whether someone is dysphoric enough to earn the right to GRS
(Hughes, 2018; Windsor, 2018).
Saketopoulou explained how this diagnostic process is rooted in the “etiological”
or the “why” of trans*ness, based on “the premise that if we can understand why then we
also know how to treat it and how to make it go away” (Blass et al., 2021, p. 989). This
premise makes the treatment of trans* individuals dependent on their therapist’s ability to
understand them, placing, as Gaztambide (2013) pointed out, “a great deal of the
responsibility for setting the conditions for [treatment] . . . on the subjectivity of the
therapist” (p. 154). The therapist’s subjectivity is an inexorable component of
contemporary, relational psychoanalytic technique, as opposed to earlier, classical modes
of analysis that discerned “gold” or “analyzable” patients—who make therapists feel
“safe and competent”—from the “copper” or “unanalyzable” patients—who make
therapists feel “unsafe, incompetent, and uncomfortable” (p. 154).
This earlier conceptualization of treatment was, as psychoanalytic doctoral
candidate Thamy Ayouch (2020) described, based on the idea that “the analyst is neutral
and benevolent”; however, she added that this idea or aspiration “is hardly enough to
cancel his/her race, gender, sexuality, or class situation: abstention does not magically
happen only because it is supposed to characterize a psychoanalyst’s position” (p. 685).
Ogden (1994) contended that “the idea of the analyst as a neutral blank screen . . . is
occupying a position of steadily diminishing importance in current conceptions of the
analytic process” (p. 3). This is especially true for relational psychoanalysis, where, as
Benjamin (1998) elucidated, “symmetry is necessary in which both self and other,”—

29
patient and therapist—“must own the burden of subjectivity, the tendency to assimilate or
deny the difference of the other (destruction)” (p. xix).
It is only in recent years that the differences in trans* experiences have been
related to anything other than negligence or resentment (Gherovici, 2017). Pula (2015)
blatantly named the “destructive” impression of trans* individuals in mainstream society
as “inherently abnormal, perverse, and psychotic,” (p. 809) and that it “is an
epistemological problem that warrants scrutiny and correction in the field of
psychoanalysis” (p. 809). Radically, Nordmarken (2014) asked whether this perceived
“monstrosity” (p. 37) of trans* patients, which differentiates them, needs to be a point of
separation between them and their therapists, or even between them and the world. What
if, instead, “people of all genders might see ourselves in each other, and that, together, we
might work against gender injustice and social distance, and toward a deeper kind of
intimacy and freedom for us all” (p. 37).
Benjamin’s (1998) invitation to embrace subjectivity and difference very closely
resembled Nordmarken’s proposition. Benjamin clarified the non-mutual exclusivity of
destruction and connection, and instead brought forth patient/therapist difference as a
point of connection through destruction, revealing “how otherness can be accepted by the
self when the attempt to psychically destroy the object is resolved through the other's
survival.” (p. xix). Drawing on Donald Winnicott, one of the most important figures of
the object-relations movement (a crucial foundation for relational psychoanalysis),
Benjamin (1998) declared that “we must not only recognize our tendency to destroy, we
must survive for the other; and we must also ask the other to take on the onus of being an
object and surviving our destruction” (p. xix).

30
Saketopoulou expanded on this, conjecturing that perhaps there are not more
trans* individuals in psychotherapy or analysis because of therapists’ inability to
“engage” trans* patients in their gender exploration, “to interest them in questions they
might have not otherwise asked about themselves” (Blass et al., 2021, p. 979). Instead,
she proffered, “if we’re starting with the premise that transition is only an option if all
else fails, then we’re also closing up space to explore things, including things that the
analyst too may not be able to forecast ahead of time” (p. 979). What therapists are
expected to know ahead of time is the entire basis for diagnosis: to assess a patient
quantifiably on just how dysphoric they are so that the therapist may decide what is right
or wrong for the patient. Saketopoulou (2020) got blunt about the fact that this is not
necessarily a ubiquitous problem in the psychotherapeutic setting, asking: “In what other
area of clinical work do analysts feel entitled to so unceremoniously abandon the
responsibility to follow the patient’s psychic reality?” (p. 1023). Saketopoulou also noted
the counter transferential issues, the unexamined subjectivity of the therapists, which “tax
the treatment” and “often [mimic] the patient’s history of being disparaged by their early
objects” (p. 1023).
The gatekeeping organization of how therapists work with trans* patients not only
forces therapists to determine whether a patient is qualified for surgery, but also to know
what surgery is or means for the patient. Psychoanalyst Alice Kentridge (2019) noted that
in the therapeutic process there can be an overemphasis on “these interventions as a form
of self-harm, a feeling that bodies are being hurt or damaged,” which may go along with
“a looking away from the violence trans bodies are subjected to out in the world”
(p. 288). Thus, what Gaztambide (2013) called the “ecological surround” and “broader

31
systems in which the [therapeutic] dyad is embedded” (p. 155) may be ignored by
therapists.
Psychoanalytic and trans* theorist Patricia Elliot (2001) espied this particularly
tunnel-vision perspective as “the more enduring source of antagonism between analysts
and transsexuals,” in that it views surgery as “an unhelpful compliance with a
transsexual’s demand to become the other sex, based on an all-consuming fantasy of
psychic redemption through physical transformation” (p. 315). Elliot went on to elaborate
on this fear of complicity and the conviction that surgery is “doomed to fail since it
confirms the fantasy that becoming the other sex will put an end to suffering and colludes
with the idea that the subject’s internal conflict can be solved by external means” (p.
316). This harkens back to Saketopoulou’s recognition that, in working with trans*
patients, the responsibility to honor a patient’s psychic reality is apparently optional, at
least when held up to a therapist’s commitment to their idea of “happiness” for the
patient, which, she asserted, “is an incredibly impoverished notion of how we understand
transitioning” (Blass et al., 2021, p. 988). Here, Saketopoulou highlighted yet another
assumption or expectation held by therapists at the threshold of decision making for their
trans* patients seeking surgery: that it will make them happy.
Trans* essayist and critic Andrea Long Chu (2018) spoke to this point in her aptly
named op-ed in The New York Times, “My New Vagina Won’t Make Me Happy (And It
Shouldn’t Have To),” that illuminated the fissure in therapeutic practice with trans*
individuals and exposed how entitled therapists determined whether surgery was good,
bad, right, or wrong, a harmless or harmful choice. Saketopoulou also pushed back on the
idea of surgery as a choice by asserting that “there are unconscious determinants for all

32
gender positions” Blass et al., 2021, p. 989). Elliot (2001) confirmed that “at the heart of
psychoanalysis is an ethical concern with the subject’s freedom to choose,” but when the
choice exists within this binary framework—right vs. wrong, life vs. death—as does the
choice of surgery for trans* patients, the process “could hardly be described as involving
authentic choice” (p. 319).
Psychologist Ken Corbett (2008) corroborated what Bell (2020) outlined as the
spectrum of transphobia and affirmation, disclosing that therapists “struggle still to find a
way to speak about non-normative genders outside a split that moves between phobia and
advocacy” (p. 849). The gatekeeping model of the therapist-trans* patient dyad in
considering GRS reinforces this binary spectrum of treatment due to the therapists’
particularly authoritative position (Gherovici, 2017). Corbett (2009) promulgated what a
psychotherapist’s job actually is:
We can only strive to hold open a potential space through which we can attempt
to assess and/or assist. . . . We can work with our patients toward their having
good-enough capacities to reflect on their complex inner worlds. We can open a
space for contemplation and recognition. (p. 387)
Elliot (2001) punctuated this credo thus: that trans* patients do not seek psychotherapy
“to have one’s decisions made for one, let alone ruled out in advance, but to help gain
further insight into one’s relationship to the body, to sexuality, to the Other, and to
oneself” (p. 319).
Knowing Ahead of Time (A Response to Informed Treatment)
Perhaps the binary or limited scope of treatment for trans* individuals has to do
with, as Saketopoulou pondered, the fact that “for varied reasons, transphobia being one

33
of them and lack of genuine curiosity and rigor being others, there has not been as much
medical research in the area of trans medicine as in other areas of medicine” Blass et al.,
2021, p. 995). Even if there was more research, Corbett (2011) asserted that, regardless,
“gender identity—the internal conviction regarding one’s gender classification—is no
longer positioned as a fixed identity or essence at a person’s core” (p. 451).
Adrienne Harris, faculty at the New York University postdoctoral program in
psychotherapy and psychoanalysis, related gender conceptualizations to chaos theory.
“You cannot know how something will turn out even if you are also working with robust
findings and concepts,” she offered, continuing with “things can feel deeply real and
bedrock and yet be constructed. All of this makes thinking about gender and sexuality
deeply interesting and unpredictable” (p. 296). Gozlan (2018) also addressed this idea in
his contention with “authentic” gender experience, utilized—in tandem with the Wrong-
Body Narrative (Hughes, 2018)— by trans* patients to convince therapists of their right
to undergo GRS. He argued that the “need for testimony, like clinging to genital notions
of identity, defends against responsibility—of not wanting to know—by settling one’s
anxiety through an answer” (p. 543). Gozlan (2008) also spoke of this anxiety around not
knowing in an earlier paper, suggesting that:
There is something about the unintelligibility of gender that is hard to bear and
that attaches to notions of prohibition—desire becomes a dangerous other
(equated with loss and absence)—and enjoyment of domination—where
normativity and certainty are celebrated—and replaces vulnerable searches for
meaning. (p. 543)

34
No sooner is a trans* individual’s desire for a procedure expressed than it is
foreclosed by the potential of regret (Saketopoulou, 2020), and the therapeutic process, as
it stands now, deigns to solve this feeling by means of knowing ahead of time. Bell
voiced his concern about this particular issue as an impetus for further research, for fear
that trans* individuals “might in a few years change their minds” about their decision to
undergo GRS, positing that “a lot of damage is done by not taking up a neutral position
and instead taking up an affirmative position” (Blass et al., 2021, p. 978).
As mentioned in the previous section, psychotherapy that is informed by the
tenets of relational psychoanalysis dismantles the myth of therapist neutrality (Ayouch,
2020; Ogden, 1994). However, affirmation can be a damaging method of engagement as
well. Gender-affirmative therapy consists of “unlearning ways of relating to others that
may be automatic or unconscious” and “[replacing] commonly used expressions . . . with
more affirming, inclusive alternatives” (Chang et al., 2019, p. 2). It also advocates for “a
means for [clinicians] to educate themselves so that . . . clients do not carry this
unnecessary burden” (p. ix). Examples of such education for therapists, such as
consuming trans* media, were mentioned in Chapter II (Carroll & Gilroy, 2002) and is
yet another way for therapists to try to know something—and not even from the patient
themselves, but from outside resources. Even through learning from the patient, the act of
affirmation recalls the question, also postulated in Chapter II, of what exactly is being
affirmed (Olver, 2019). Ostensibly, the patient’s gender is being affirmed, but if Harris’s
(2011) musings on chaos theory are applicable to the trans* experience, then affirmation
as a tool or intervention is at best a flimsy arrow flinging toward an ever-moving target.
Clinical psychologist and psychoanalyst Alessandra Lemma (2018) also noticed this

35
stalemate and deduced that “the challenge is to tread the fine line between a dialogue
based on an equidistant curiosity about meaning and function that is core to an analytic
approach, and a posture of implicit skepticism” (p. 1089).
Although the Informed Consent model, like the Affirmative model, poses an
alternative to the transphobia and pathologizing of the gatekeeping model (Hughes, 2018;
Schulz, 2018; Levine, 2019) it, too, depends on trans* patients knowing, or trying to
know, something ahead of time, like “the nature of [their lives] in 10-20 years” (Levine,
2019, p. 221). In this way it also imitates a foundational element of the gatekeeping
arrangement, which demands “authenticity” from a trans* patient in describing their
experience, and upholds it as “that which is given, permanent, and cohesive, as that
which guarantees the legitimacy of our identity claims: I always was and always had been
gender-coherent” (Gozlan, 2018, p. 7). Benjamin (1998) also established that “gender
works in us not through something as stable or coherent as an identity” (p. 37), and
Gozlan (2008) argued that “when the armor of identity softens, subjectivity regains
significance” (p. 564). Moreover, he added that the “concreteness” of identity “occurs in
response to the threat of difference” (p. 546). Clinical practitioner and psychoanalyst
Melanie Suchet (2011) confessed her own vocational reckoning when faced with this
difference, in the midst of long-term analysis with her patient, Rebecca, who came out as
trans*. “I make a conscious decision to resist my urge to read everything I can on the
subject with the fantasy that I will understand it all,” she reported, “I have to let myself
feel the anxiety of not knowing, of exploring unfamiliar territory, just as [the patient] is”
(p. 175).

36
Of course, the Informed Consent and Affirmative models of treatment for trans*
individuals were conceived with the intention of reducing the exceedingly asymmetrical
status of the therapist in the dyad and to increase patient agency in pursuing GRS.
However, these models emphasize knowing or trying to know, which is an act that is
inherently antithetical to the trans* experience, as it perpetuates an “investment in
normativity” (Gozlan, 2008, p. 564) and risks “erasing trans in favor of psychic
bisexuality that orbits around two genders only” (Blass et al., 2021, p. 975). Another
treatment for trans* patients is a relational psychoanalytic approach, which Gozlan
(2008) defined as:
The ability to play in the realm of phantasy (one’s own and the patient’s)
that composes therapeutic action. It requires acceptance of impotence:
There is never a known subject, including the analyst. Analysis simply
offers a way to think about what one does with what belongs to the self.
(p. 564)
GRS Beyond Solution: What if There is Nothing to Fix?
Probably the most binary aspect of treatment for trans* individuals seeking GRS
is that an inordinate amount of attention is given to (as a considerable portion of this
thesis has demonstrated so far) whether a patient should or can undergo GRS, or whether
a patient should not or cannot undergo GRS. This bifurcated, yes/no fixation takes place
at the expense of everything to consider surrounding the surgery, or what relational
psychoanalysts like Benjamin (2011) and Ogden (1994) might interpret as what
comprises the Third in the psychotherapeutic field. The most salient thematic aspects of

37
the field that I have identified in contemporary psychoanalytic discussions of working
with trans* patients interested in GRS are waiting, imagining, and mourning.
Waiting
The idea of “waiting” before undergoing GRS was a major point of contention in
a recent debate between Saketopoulou and Bell, with Bell arguing for waiting as a means
of forestalling potential damage and Saketopoulou insisting that waiting is not an empty
space but an action in itself that can be damaging (Blass et al., 2021). I agree with
Saketopoulou that waiting is action, but not necessarily that it is damaging. If we
acknowledge waiting as an activity, we may first clarify that “an ‘act’ does not describe
movement or a physical action. It refers to a signifying act that captures both certainty
and doubt” (Gozlan, 2011, p. 48). What is certain is that acknowledging the original body
of the trans* individual is an emotion-filled experience. Lemma (2015) warned that this
process “requires painful work that involves facing loss and acknowledging dependency”
(p. 97). Some of this painful work may include “naming and processing the anguish
brought to these patients by their bodies” (Saketopoulou, 2014, p. 782).
Although this work is undoubtedly uncomfortable, Atalia Israeli-Nevo (2018), a
sociological and anthropological researcher on transsexualism, wrote that in her own
experience of transitioning “taking time is a way of thinking and experiencing life and
body through delay and untimeliness,” which “may cause moments of deep introspection
about trans identity, both in the trans subject and in the people surrounding
him/her/them” (p. 65). Such introspection that may occur during waiting—or taking
time—can invite the question of “what is gender anyway?” (Gozlan, 2018, p. 5) before
moving on to concretize it in the body.

38
Suchet (2011) recounted a session with her patient Rebecca who expressed that “I
have to be a boy to be a girl,” to which Suchet clarified, “You have to be that which you
are not to allow for that which you are?” (p. 177), and her patient agreed. Suchet then
“[showed] her the path of her associations, from hatred and shame about her body to
surgery, as if surgery could be a way of getting rid of her feelings” (p. 178). Suchet’s
experience with Rebecca reflects Gozlan’s (2011) proposal that “the act of analysis is the
act of becoming a subject in gender” where “the transsexual body can function much like
free association, a technique whose aim is not to arrive at a final truth” (p. 49). This
process requires the ability “to tolerate the incompleteness of knowledge” (Gozlan, 2011,
p. 49) including “doubt” (p. 48)—an indisputable component of waiting and hence an
additional angle on the critique of knowing in previous sections of this thesis. Suchet’s
(2011) documentation of this process with Rebecca—of tolerating the unknown and not-
yet-understood—did in fact lead to insights, awareness, and understanding that he could
“not come to accept his body as it is” (p. 182).
Saketopoulou (2014) qualified this process and argued that even if it leads to
“eventually accepting the body one was born into,” that acceptance is not synonymous
with “resolving [trans*] individuals’ need for surgical and hormonal intervention”
(p. 782). Trans* writer and critic Jay Prosser asserted that “since the problem [for trans*
individuals] is located in the material body, intervention needs to be at that level, by
surgically altering the flesh rather than psychologically altering body image” (1998, as
cited in Suchet, 2011, p. 179). Although this attitude is reminiscent of Benjamin’s
insistence from the mid-20th century on aligning the trans* patient’s body with their
mind, Prosser’s statement takes on new resonance in the contemporary trans* experience.

39
Israeli-Nevo (2018), although a proponent of “taking one’s time in transition”
(p. 69), also acknowledged “the dangers of the present” (p. 65), specifically for those
trans* persons suffering from “a lack of resources, social neglect, and marginalization”
(p. 67). For such individuals, GRS holds more urgency, with a goal of safely passing as
one gender or the other. Even if safety is not an immediate issue, Saketopoulou
contended that “fluidity will not capture some peoples’ gender sufficiently” (Blass et al.,
2021, p. 976). Even more astutely, Saketopoulou—in response to Bell’s attempt to
equating questioning with waiting and perhaps with “an eye towards slowing [trans*
patients] down”— declared that “whether it can create time, or not, is not something that
I have control over” (p. 987). This declaration illustrates the heart of waiting, not as a
measure of time, per se, but as an act of engagement, where “what distinguishes an Act
from acting out is not the activity but its ability to be enjoyed as lacking” (Gozlan, 2011,
p. 49). Enjoyment as used here should be understood as a quality of being that is perhaps
less about joy than about curiosity, thoughtfulness, and imagination. The act of waiting to
undergo GRS, then, is not geared toward a desirable or undesirable arrival, but, rather, is
an expansive experience in itself.
Imagining
In an interview with Gayle Salamon, Professor of Princeton University’s program
in gender and sexuality studies, about her book Assuming a Body: Transgender and
Rhetorics of Materiality, Ken Corbett noticed that in Salamon’s writing, “the body . . .
becomes less a noun and something more akin to a verb” (Salamon & Corbett, 2011,
p. 222). In her response, Salamon verified the idea of “the body as . . . a potential space”
and as such “not aligned with presence, materiality, wholeness, and mastery, but

40
dividedness, absence, the struggle for recognition and the peril of misrecognition”
(p. 223). In her work with trans* individuals, Lemma (2015) recognized this quality of
dividedness and misrecognition as “not simply as a matter of gender and sexuality but as
a disruption in identity coherence” (p. 100). The anxious feelings that may be evoked
from in-betweenness (Nordmarken, 2014) have been equated by psychoanalyst Rosine
Josef Perelberg (2018) with “the original experience of helplessness . . . an affective state
that is accompanied by physical sensations and bodily symptoms— expression of an
excess that it is not possible to process psychically” (p. 810). This excess of feeling,
which Lemma (2015) designated as the “unmentalized incongruity at the level of the
body-self,” is, in her observations, a strong contributor to “the search for the ‘right’
body” and the hope that this body “will relieve the incongruity through the certainty it
imparts that the image in the mirror . . . will match the subjective experience of the body”
(p. 100). Like Suchet (2011), Elliot (2001) referenced Prosser to verify her determination
that “transsexuals can neither adopt nor reject beliefs in continuity until they can ‘own’
their own bodies” (p. 302), which leads them to “pursue embodiment through surgical
transformation” (p. 306).
Suchet (2011) expressed her ambivalence about Rebecca undergoing GRS and
pondered that “changing one’s body doesn’t fit with the psychoanalytic model of working
through intrapsychic conflict” (p.178). Suchet revealed, similarly to her own patient, an
inability to manage a split (Elliot, 2001) between the physical and the psychological. At
the core of Suchet’s ambivalence is the unexamined assumption of trans* embodiment
through GRS as a “solution” (Elliot, 2001, p. 314) or answer to the question “is
somebody trans[?],” which re-establishes the treatment on a binary, “right track-or not”

41
spectrum (Saketopoulou, in Blass et al., 2021, p. 982). Gozlan (2008) articulated that
“the literalization of the body is not likely, or even desired, to be given up” because “the
cost of such relinquishments is fear of annihilation” (p. 560).
It should certainly not be the therapist’s practice to exacerbate this literalization.
The therapist must recognize that “the feeling of disembodiment tends to be taken at face
value as if it expressed in some straightforward way the truth of the body, with no subject
to name, to interpret, or to question it” (Elliot, 2001, p. 314). At the same time, the
therapist must also understand this as emotional pain, which Ogden (2004) defined as the
state of being “unable to dream (i.e. unable to do unconscious psychological work) . . .
emotional experience,” and thus “unable to change, or to grow, or to become anything
other than who he has been” (p. 862). Although Ogden was not discussing the experience
of exclusively trans* patients, Salamon’s illustrations of the trans* experience displayed
this inability to dream in that “the bio ‘real’ body— through a kind of radical certitude—
forecloses the horizon of possibility both in modes of explanation (the archive) and in
modes of experience (the yet to happen)” (Salamon & Corbett, 2011, p. 226). Elliot
(2001) believed that “this is where psychoanalytic inquiry can make its contribution”
(p. 314), and Ogden (2004) qualified its contribution as dependent on “conditions in
which the analysand (with the analyst’s participation) may become better able to dream
his undreamt and interrupted dreams,” including “those of a third subject who is both and
neither patient and analyst” (p. 862).
Suchet (2011) poignantly recounted a session with Raphael (FKA Rebecca) after
years of analysis, wherein he was able to “explore going inside himself, imagining
himself as a woman with a woman’s body” (p. 185) for the first time in their process. “He

42
confirms that it is only possible because he is now secure in his masculine identity,”
Suchet reported, which, of course, he had been helped to arrive at through the conditions
of the psychotherapeutic container they had co-created. Benjamin (2011) described
relational psychoanalysis as “an invitation to face reality together. A most powerful
instantiation of surrendering to the Third, to ‘life as it really is, not as we wish it to be’”
(p. 29), which Suchet (2011) and her patient had, by this time in their treatment, made a
valiant effort to do. They strove to “[live] in a space of gender uncertainty in a world that
does not tolerate gender ambiguity” (p. 186).
In Ogden’s (2004) words, Suchet’s patient became more able to “[dream] his own
experience, thereby dreaming himself more fully into existence” (p. 862), where
dreaming could be compared to the aspirations of Lemma’s (2015) identity coherence, or
Elliot’s (2001) continuity. It is important to discern these qualities (coherence, continuity)
from that of completeness, which turns a quality of being (coherent, continuous) into a
closed circle of experience or illusory arrival. Gozlan (2008) expounded that “the
phantasy of completeness and the idealization of a phantasized absolute congruency
prevent the transsexual from feeling ‘good enough’ and lead to an inability to take in the
other as the result of anxiety” (p. 566). This, in turn, inhibits what Benjamin (1998)
outlined as the “double task of recognition in psychoanalysis” or “the matter of how we
use our marvelous capacity for identification with others . . . to bridge or obfuscate
differences between us” (p. xiii). “I am concerned with how we do both at once” she
continued, which, in a binarily gendered world (Suchet, 2011) is a radical and imperative
effort in the treatment of trans* individuals, especially in imagining the potentialities of
GRS. I propose imagining the body—as it is, as it has been, as the patient hopes or fears

43
it will be—not with an aim towards concrete realization, but as an process that may yield
a sense of embodiment before any physical realization occurs.
Mourning
If desire, as Gozlan (2008) hypothesized, “rests on incompleteness, suspense, and
yearning,” then it is a through-line between waiting, imagining, and mourning, and is
sustained by the idea that “there is never complete knowledge of ‘one,’ therefore there is
never a complete gender or a normal self” (p. 563). “The first mourning work any of us
do,” Hansbury (2005) claimed, “is to grieve the loss of abstraction; specifically, an ideal”
(p. 22). He was referring to the original rupture of the infant-mother relationship, but this
may certainly be applied to trans* patients pursuing GRS, who are driven by “an
idealization and an envy of the ‘Other’s’ completeness” (Gozlan, 2008, p. 568). Elliot
(2001) named this “the fantasy that becoming the other sex through surgical
transformation will make one a wholly different person, a person who will have escaped
or transcended conflict and alienation,” which is exactly what instills the fear in therapists
of “complicity” with trans* patients’ desire for GRS for fear that it “colludes with the
idea that the subject’s internal conflict can be solved by external means” (p. 316). But, as
Saketopoulou appealed, the goals of “happiness” or “magical solutions” (Blass et al.,
2021, p. 988) are, at best, binary simplifications or “gendered adaptations and solutions
that we come up with” (p. 982). Or, at worst, assumptions made by the therapist at the
negligence of inviting in the trans* patient’s lived experience.
Using a relational model instead, Benjamin (2011) extended, would be “calling
upon the space of intersubjectivity to share a Third that is in fact not unconscious” and
that “dissolves the idealization of what could or should have been” (p. 29). Reiterating

44
Ogden’s (2004) emphasis on conditions, Gozlan (2008) also insisted that the therapeutic
container “must create the conditions for accepting the transsexual dilemma as a human
condition” (p. 563). Acceptance, here, is not exclusive to the trans* patient’s
psychotherapeutic journey, but the therapist’s as well. Regarding Raphael, Suchet (2011)
eventually had to accept her realization that “something fundamental cannot shift until he
alters his body” (p. 182). The same applies to mourning, as, in this realization, Suchet
(2011) admitted, “I am tussling with the theoretical challenges as I slowly find myself
giving up my allegiance to what I thought I knew” (p. 182). There was a need to mourn
aspects of her psychoanalytic training that had not prepared her for the sort of experience
her trans* patient was having. In this way, the therapist’s willingness to consider “a
different kind of ideal object, one that might be loveable in its imperfect reality”
(Benjamin, 2011, p. 29) may help the patient understand failure as an inevitability of
gender (Gozlan, 2008) and thus mourn GRS “as gender embodiment . . . for its failure as
a guarantee of perfection” (p. 568).
However, “giving up the fantasized aspects of surgical reassignment,” Elliot
(2001) contended, “does not mean giving up the desire to bring the body into conformity
with gender identity” (p. 316). Suchet (2011), realizing that her patient would not be able
to progress psychically without GRS, argued that “this does not diminish the fact that
there are reasons why he feels the way he does regarding his body, but it no longer feels
that these reasons have to preclude physical change” (p. 182). As Elliot (2001) professed,
“perhaps [surgery] is not the unmitigated failure that psychoanalysts fear” (p. 318),
especially if both therapist and patient are able to mourn their fantasies (of the ideal

45
treatment, of the ideal gender expression), to make way for a “more authentic
conversation” (Benjamin, 2011, p. 29).
Clinical Applications
A momentous turning point in Suchet’s (2011) process with Raphael was the
consideration to “contemplate surgery as possibly therapeutic” (p. 179). As I have argued
here, the primary attitude that mental health professionals hold about GRS has been, and
in some cases continues to be, a binary one, with the perception that it can be either a
solution or a mistake. What Suchet’s realization communicates instead, and what I have
identified as a theme in the practices of many contemporary psychoanalytic thinkers
working clinically with trans* patients, is the potentiality for GRS to be a part of the
process, and thus but a point of experience in the constellation of experiences a trans*
person has on their journey. Although there is research to suggest that GRS greatly
improves the lives of trans* patients (Blass et al., 2021), one fundamental assumption that
I have investigated is the idea that patients, and especially therapists, can know what will
improve their lives conclusively, without doubt or regret. Saketopoulou candidly asked,
“since when did psychoanalysis make it its province to prevent patients’ regrets about
their decisions?” (Blass et al., 2011, p. 993) and highlighted the fallacy that therapists
have any power to predict the future, specifically when it comes to regret. When it comes
to making any decision, a necessary step in that process is the state of ambivalence,
which, according to the Merriam-Webster Dictionary (n.d.), is defined as: “simultaneous
and contradictory attitudes or feelings…toward an object, person, or action,” “a continual
fluctuation (as between one thing and its opposite),” and “uncertainty as to which
approach to follow.”

46
The radical perspective presented in the texts I have drawn from in this chapter is
that ambivalence need not be a steppingstone en route to the destination of decision, but
can be a potent, alive, and ephemeral state of being that may continue beyond the point a
decision is made. If ambivalence and decision need not be mutually exclusive, then, as
applied to treatment with trans* individuals seeking GRS, neither do psychotherapy and
surgery (Elliot, 2001; Suchet, 2011). Rather, they may interweave in an imaginative braid
of consideration, as Gozlan (2008) envisioned:
Psychoanalysis can help the [trans* patient] where technology fails . . .
Psychoanalysis does not help to solve anxiety over gender or discontent with
one’s body, or take away the wish to be complete. It can only identify
moments where we are stuck in our normativity, where we inhibit desire.
Helping [trans*] patients tolerate identity without intelligibility is primary in
allowing them to tolerate their creativity. (p. 568)

47
Chapter IV
Summary and Conclusions
Summary
Over the past century, characterizations of trans* individuals have ranged from
psychopathological to progressively radical, inviting stigmatization, pathologizing, and
fetishizing from the public and mental health professional spheres alike (Gherovici, 2017;
Gozlan, 2018). Although these attitudes have adversely affected the trans* population on
many levels, the research problem I identified is the inherently binary and consequently
gendered procedures currently in place in the determination of trans* individuals’
attainment of Gender Reassignment Surgery (GRS). From the evolution of GID as it is
defined in the DSM-5 (APA, 2103), to the assessments required by counselors and
therapists (Carroll & Gilroy, 2002; Carroll et al.,2002; Levine 2019), to the ultimate
positioning of the counselor/therapist as the final word on receipt of services (Hughes,
2018; Schultz, 2018), the most current practices in the treatment of trans* individuals
locate the psychotherapeutic process in a bifurcated landscape that forces both therapist
and patient to choose between knowing/not-knowing, the concrete/the symbolic, and
advocacy/phobia (Bell, 2020; Eliot, 2001; Gozlan, 2008; Gozlan, 2011; Pilgrim, 2018;
Roen, 2002). The limitations of this experience, however, do not go unnoticed by a
contingency of contemporary psychoanalytically-informed clinicians, who attempt, by
engaging in a process that is parallel to gender theory itself, to explode the linearity of
trans* treatment into a constellated method of being-with (Hansbury, 2005; Israeli-Nevo,

48
2018; Lemma, 2015; Lemma, 2018; Losty & O’Connor, 2018; Saketopoulou; 2014;
Saketopoulou, 2020; Suchet, 2011).
Conclusions
In my own pursuit of GRS, I could very easily arrange a consultation with a
surgeon, invest in the appropriate insurance plan, and even schedule a date to
receive the surgery. The last item I required was a support letter from my therapist to
submit to the insurance company subsidizing my surgery. Without insurance, the cost
would jump from $1,700 to over $9,000. However, I was resistant to, or at the very least
ambivalent about, asking my therapist for such a letter, understanding that its purpose
would be confirmation of my gender dysphoria “through narratives of being trapped in
the wrong body” (Gozlan, 2018, p. 5), as well as my conviction that GRS would resolve
any “somatic incongruence” (Olver, 2019, p. 1) and perhaps even promise gender
euphoria. I, however, was not confident of either of these positions, and my ambivalence
made me feel as though I could not qualify for medical support, even though
ambivalence, confusion, and nonconformity were exactly the aspects of gender that I
wanted to walk toward.
Herein lies the inception of my research question. In my research I found that my
anxiety about gender ambiguity was reflected in recent studies on working with trans*
patients, particularly when it came to receiving GRS. While certain researchers and
clinicians advocated for a “wait and see” approach in the therapeutic process with trans*
patients desiring surgical intervention (Bell, 2020; Iraeli-Nevo, 2018), others emphasized
that such a stance was a privilege, that the ability to wait and see was dependent on race,
class, and access (Blass et al., 2021; Israeli-Nevo, 2018; Roen, 2002). Moreover, the

49
suggestion of waiting risked the mark of transphobia (Bell, 2020). Such polarizing points
of view on GRS were also present in recent texts in gender theory, with some claiming it
as a tool with which to “destabilize the categories ‘woman,’ ‘transsexual,’ and ‘man’”
(Roen, 2002, p. 503) and others going so far as to proclaim GRS as “the most brutal
affirmation of gender stereotypes” (Olver, 2019, p. 1). In my quest to gain some clarity
on my own confusion and ambivalence about GRS, I was met with an infinity mirror of
evidence that could perpetuate my cyclical thinking around this topic ad infinitum.
In regard to present clinical attitudes about GRS, there has certainly been
evolution in the form of increasing confrontation or questioning of “‘either-or’ messages
about sex reassignment surgery,” manifesting as “[pressuring] clients prematurely to
come out to others and appear as the other gender” (Carroll & Gilroy, 2002, p. 233).
Moreover, there is increasing acceptance of the fact that “many nontraditionally-
identified persons [do] not want to alter their bodies surgically or hormonally, [do] not
identify with the feeling of being ‘trapped in the wrong body,’ or could not afford the
cost associated with surgical and hormonal interventions” (p. 234).
However, this evolution in the clinical attitudes has, in some ways, ballooned into
a bypassing of this uncomfortable territory of “Choose Your Own Adventure” gender
ambivalence via adoption of a “‘trans-positive’ or ‘trans-affirmative’ disposition to
counseling” (Carroll et al., 2002, p. 133). This disposition, although preferable to the
clinical othering of trans* people in the past, is brought forth as a process of education
and training wherein clinicians must “build an adequate knowledge base” of “political,
historical and psychological contexts” (p. 133) as well as autobiography, art, and
academic writing. This penchant for knowing on behalf of clinicians, though well-

50
intentioned, undermines the not-knowing that must be held the therapeutic container with
a *trans individual considering GRS and reinforces the argument that questioning,
thinking over time, or waiting are clinically transphobic (Bell, 2020; Gozlan, 2018). In
response to these bifurcated stances, I invited in the ideologies of contemporary
psychoanalytic thinkers—the most salient of which is relational analysis—to widen the
field of possibilities in this increasingly common therapeutic process. On the practice of
relational analysis, Belkin (2020) argued:
Psychoanalytic inquiry reveals the hubris of self-knowledge, clashes with our
familiar representations of other people, and makes us reflect on our habitual
ways of ignoring what we do know. Along the way, inquisitiveness often serves
as a buffer against the anxiety generated by uncertainty and ambiguity. (p. 15)
This is an important discernment from those practices that grasp at etiological methods to
combat the discomfort of not knowing, offering instead an embrace of not-knowing
which invites rather than forecloses possibilities for the patient.
Clinical Implications and Future Research
My hope for this thesis is that it may help mental health practitioners better
understand the medical-therapeutic relationship as it pertains to trans* clients seeking
GRS, and further, inspire practitioners to move beyond this existing framework at the
micro (individual therapy) and macro (patient advocacy) levels. In an individual
therapeutic setting, my research findings may help thaw the frozen elements between
therapists and trans* patients, moving the discussion around GRS from the binary debate
of “should I or shouldn’t I?” and into a constellation of relational experiencing that
aspires to be as or more valuable than any conclusive decision or result. As with any

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