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Clinical Psychologist Reframes Gender Dysphoria as a Body Image Disorder

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In a recent study, clinical psychologist Jaco van Zyl redefined gender dysphoria as an affective-perceptual disturbance involving the body. Published in Psychodynamic Practice, this study challenges the prevailing gender-affirmative approaches, suggesting that a psychoanalytic framework may offer a more nuanced and ethical way to treat gender distress, particularly in minors.

The findings of the WPATH Files in Canada and Hilary Cass’ Final Report in Britain have made the treatment of gender distress among minors a contentious issue. Both reports raise critical concerns regarding informed consent, duty of care, child safeguarding, and the efficacy of research-derived treatment protocols. The debate often sees identitarian ideologies clashing with clinical perspectives, making it crucial to separate ideological beliefs from scientific theorising when addressing gender dysphoria.

What motivated the publication of Van Zyl’s paper was the emerging evidence of ideological takeover of the psychological and medical fields, as well as the subsequent harm done to vulnerable individuals – underage children, no less. Van Zyl said: “The treatment of gender distress in minors remains contentious, as identitarian ideologies have entered into these debates. Endorsing a grievance-based ideology that targets natural phenomena for subversion poses a challenge for both clinicians and gender-distressed patients. Identitarian group formation and the young patient’s identification with the group may greatly impede psychotherapeutic work.”

Van Zyl’s study critiques the gender-affirmative psychotherapy model, which he argues neglects the core principles of psychoanalysis by failing to integrate the reality principle. According to Van Zyl, gender-affirmative approaches often align with identitarian ideologies, potentially leading to the detriment of overall psychological health by prioritising immediate pleasure over long-term well-being.

Van Zyl’s study views gender dysphoria through a psychoanalytic lens, considering it alongside other body image disorders such as anorexia nervosa, body dysmorphic disorder, and muscle dysmorphia. These conditions share an affective component of depression and anxious distress linked to perceptual distortions about the body. Van Zyl builds a thorough formulation of the development of body image disorders, or affective-perceptual disturbances involving the body, using the psychoanalytic theories of Sigmund Freud and Wilfred Bion. He demonstrates that, as with the other body image disorders, gender dysphoria involves the enactment of early defensive strategies as a defence against underlying distress.

By applying Freudian and Bionian concepts of psychological maturation, Van Zyl illustrates how affective-perceptual disturbances can develop. He argues that gender distress should be understood as part of this broader category of psychological disturbances, rather than as an isolated phenomenon. This perspective challenges the gender-affirmative model, which Van Zyl claims fails to address the underlying psychodynamics of gender dysphoria. “The maladaptive defence aimed at reducing the anguish associated with loss usually involves the physical modification of the body part or feature to align with their imagined ideal. Perceptive, ethical, and well-trained clinicians would understand that what is presented as the cause of their distress is most often the target of affective discharge (also called transference acting-out), fuelled by deep, unconceptualised regret, envy, and aggression, whose source may reside elsewhere.”

Van Zyl’s study highlights the limitations of gender-affirmative psychotherapy, suggesting that it often colludes with primitive defences that prevent psychological maturation. He argues that this model mistakenly interprets gender distress as the source of psychic suffering rather than a symptom of deeper, unresolved issues. Informed by decades of research and application of psychoanalytic insights, Van Zyl points to the wrongheadedness of gender-affirmative practices as a therapeutic modality. Instead, he encourages the use of tried and tested exploratory psychotherapy as the golden standard of care: “Exploratory therapy is a resumption of psychological integration and development, prematurely arrested due to maladaptive defensive strategies.”

The study references developmental psychology research, which shows that identity in early childhood and adolescence is transient and subject to change. Van Zyl criticises the unthinking assumption that children can articulate an authentic gender identity, pointing out that many gender disturbances are temporary and can be found in various neuroses and personality disorders.

Van Zyl advocates for gender-exploratory psychotherapy, which he argues is better suited to address the psychodynamics of gender dysphoria. This approach involves a curious and open-ended exploration of the individual’s experiences and feelings, rather than a pre-emptive affirmation of their expressed gender identity. To compare exploratory therapy to the early stages of a baby’s development, it includes both the mother’s role of helping and the father’s role of coping with outside reality. This method aims to resolve maladaptive defence mechanisms and promote psychological integration and maturation, offering a pathway to understand and work through underlying distress.

As more clinicians realise the extent of malpractice involved in gender-affirmative approaches, we will hopefully see a return to ethical and responsible treatment of gender dysphoria. The findings of Van Zyl’s study underscore the importance of considering psychoanalytic principles in the treatment of gender dysphoria. The study aligns with the recommendations of Hilary Cass, suggesting that gender distress should neither be immediately affirmed nor targeted for change, but rather understood and explored.

Van Zyl concludes that exploratory psychotherapy represents an ethical and responsible approach to treating gender dysphoria, particularly in minors. By addressing the deeper psychological issues and facilitating a gradual process of self-discovery and acceptance, this method aims to provide a more sustainable and holistic resolution to gender distress.

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