A psychoanalytic view of ‘understanding’ and of ‘absence of controlling influences’

Decisions about medical transitioning require access to factual data about the risks associated with these interventions and an understanding of the personal relevance of these risks for a given individual. ‘Understanding’, as we use the term here, is not restricted to cognitive understanding of medical facts, but we suggest that it should also involve self-understanding. This requires, as Freud put it, learning ‘first to know yourself’.22 This amounts to more than an intellectual understanding. Self-understanding, as conceptualised psychoanalytically, is about reducing the absence of controlling influences through broadening the scope of our awareness of the unconscious determinants of our decisions. By ‘controlling influences’ we have in mind, for example, the impact of external family and/or cultural pressures that are implicitly operating on our minds. We also consider the control exerted unconsciously by repetitive patterns in relationships with others and in relation to one’s ‘self’ that dominate an individual due to their life experiences and psychic defence structures. We will illustrate this shortly through consideration of Sam’s case.

What is meant by ‘self-understanding’ in psychoanalysis rests on some key assumptions about the mind that we will outline, but not defend, in this paper (for a fuller discussion see23):

1. We have a conscious as well as an unconscious mental life. Meaning systems thus include both conscious (i.e., verbalisable) and unconscious aspects of experience.

2. We all have a developmental history and a current life: both need to be understood if we are to understand ourselves and our decisions.

3. Our developmental history is relevant to self-understanding because our early attachments contribute to relationship templates that are often implicit (i.e., they operate without our conscious awareness) and that continue to shape behaviour in the present through the implicit activation of expectations of the self and of others. This ‘internal world’ of relationships gives texture and colour to each new situation that we encounter in the present: meanings and unconscious fantasies shape behaviour, thinking and feeling, and hence our decisions, whether or not they are the originators of the behaviour, thought or feeling.

Self-consciousness is considered a distinctive feature of human beings (and some ‘higher’ non-human animals) and is a central requirement for autonomy. We suggest that acknowledging the influence of unconscious mentation is also important. In considering the unconscious we have in mind not only the much-rehearsed question of unconscious brain processes that are precursors to an experienced choice24, but also how a significant proportion of our emotional reactions is controlled by automatic, unconscious structures, bypassing consciousness altogether.25 Research suggests that the same principles that apply to cognition operate with unconscious (implicit) affective and motivational processes as well. The so-called cognitive unconscious26 is now recognised to be the cognitive–affective–motivational unconscious.27 28

Research on unconscious affect provides persuasive evidence that we can feel things without conscious awareness that we feel them and that we can act on feelings of which we are unaware.29 30 Studies of subliminal perception, implicit cognition and directed forgetting have all shown how emotion processing can bypass the cortex and can proceed without conscious awareness.29–33 Classically conditioned emotional responses (e.g., expectations, preferences, desires) constitute the affective colouring of our lives. They orient us unconsciously to aspects of our environment and to particular types of relationships and inform the decisions we make. Often, there is no conscious memory connected with this learning. This makes it possible for emotionally charged schemas to be repeated without the mediation of consciousness.

Our perceptual system has evolved in response to the need to perceive not only accurately but also speedily. The brain has thus developed a split perceptual system.29 The slower perceptual system involves the cortex and includes conscious awareness. This system allows for more detailed information to be gathered, which in turn, helps us to inhibit responses and initiate alternative behaviours. The other system ‘‘fast-tracks’’ perception bypassing the cortex. This system does not involve any conscious awareness. The problem with the ‘‘fast-track’’ system is that it does not allow for a more fine-grained appraisal of what we are perceiving and responding to: it is not reflective. This means that when this system is activated, past experiences run a greater chance of impacting current experience though associative connections that are not reflected on, even when these may not be relevant or helpful to the immediate present. Current situations that are emotionally arousing, and where the capacity to reflect on experience is diminished by internal and/or external factors, are more susceptible to being fast-tracked. Risks to autonomy are posed when the decisions we make under these conditions are further fast-tracked by medical protocols that don’t do justice to the complexity of the unconscious factors that may be driving decisions. This is especially so when the decisions concern the subjective experience of identity, as we will now illustrate through a case study. The case is fictional and does not relate the history of any patient(s). However, the issues have been informed by the clinical psychoanalytic work by one of us (AL).

Sam, a natal girl, decided to transition from female to male during middle adolescence. The parents wholeheartedly supported this decision. They said that Sam had always been ‘tomboyish’. They were concerned about how depressed he had become, which the parents linked to body dysphoria. Sam scoured the internet for information about his difficulties and found solace in the narratives he read on trans websites. Following three consultations with a specialist GID, Sam was placed on cross sex hormones and changed his name.

At first Sam’s mood improved. He felt very connected to the trans community that he met online, and this eased some of his isolation. However, a year after starting cross-sex hormones, Sam took a serious overdose and was admitted to an in-patient facility. It was only at this point that he was referred for psychological help.

During the process of psychotherapy that ensued, it quickly emerged that Sam’s much older brother had died unexpectedly when Sam was still a very young child. The brother had been a strong presence in the family and Sam thought that his mother preferred him. He felt that his mother had never really recovered from this tragic loss. He conveyed how he had tried hard to please her as best he could and how upset he was when he felt unable to assuage her loss.

As a younger child, Sam did not recall wanting to be a boy, but he was clear that he had taken a strong interest in more typically ‘male’ sports (like Sam knew that the brother had done) and preferred playing with boys, which had alienated him from the girls at school. The parents had told Sam that he had expressed a strong wish to have been born a boy when he was at primary school. Sam had no recollection of saying this to them, but at the start of therapy he was nevertheless adamant that this was how he had always felt.

When Sam eventually decided that he wanted to transition, the parents were very supportive. Sam recalled feeling closer to them than ever before. He had the impression that they were happier overall, especially his mother. Over time in the therapy, it became clear that, as far as Sam was concerned, the decision to transition had facilitated a closeness between him and his mother that he had always longed for.

The parents appeared to have been very invested in Sam’s decision, even hurrying the process of starting hormones and attributed the suicide attempt exclusively to Sam’s gender dysphoria. The suicide attempt accelerated their belief that Sam should undergo sex reassignment surgery at the earliest opportunity. Yet Sam’s own account of the events leading to the suicide attempt did not appear to be evidently connected to gender dysphoria. Rather, the suicide attempt seemed to have been triggered by Sam’s feelings of distress and anger after the parents missed an important celebratory event in Sam’s life because it coincided with the anniversary of his brother’s death, which they always marked, and around which Sam often felt very uncomfortable.

The brother’s ‘ghost’ dominated the family’s collective psyche, for example, the brother’s bedroom had been preserved and Sam was often compared with his brother. Sam had very little memory of his brother and at times he resented the brother’s ongoing presence and preference in the mother’s mind. Sam was tortured by guilt that he had survived his brother as well as guilt about his resentment towards him for taking up the parents’ mental space which Sam wanted to claim for himself.

Sam had grown up in his brother’s shadow engulfed by the parents’ unresolved grief. In the context of therapy, Sam came to understand that the only way that he had felt he could be ‘seen’ by his parents was to effectively become their ‘son’ through transitioning. Yet, despite starting medical transitioning, Sam was soon confronted with the actual impossibility of replacing his brother. This became painfully clear to him when his parents cancelled their attendance at a celebratory event for Sam because it coincided with the anniversary of his brother’s death. Sam’s suicide attempt was another way in which he used his body to recall his parents’ attention to his existence and needs. But their misreading, as it were, of why he had tried to kill himself, left Sam feeling alienated from them and confused about whether he should seek sex reassignment surgery.

We will not discuss this case further but suffice to say that Sam’s trajectory following the suicide attempt was punctuated by a series of crises and a prolonged depressive state marked by confusion over his identity and uncertainty as to whether he had made the right decision to commence transitioning. As the family dynamics were consciously articulated, gender identity receded in Sam’s mind as either the problem or the solution and the focus turned instead to Sam’s distress and grievance towards his parents for what he had experienced as their neglect of his needs. Awareness of how the unresolved family grief and his own longing to be the replacement son had informed his transgender identification enabled him to make informed choices about the best next steps for him.

Unconscious aspects of identity

A central contribution by psychoanalysis to discussions about identity is that it destabilises any such notions by introducing the role of the unconscious and the ‘speciousness’ of identity itself.34 Tying down identity primarily to social processes and conscious choice denudes the notion of its essentially conflictual nature and of its intimate connection with desire and unconscious fantasy.

The sexed body, social gender and sexuality (i.e., desire) are all constitutive of identity. Gender identity is not an indicator of sexual orientation and both are nowadays conceptualised as independent of sexed bodies. The value of a psychoanalytic perspective on gender and sexuality is that it reveals that the relationship between a body part and its sexual function or its gendered significance is at best one of ‘lightly tethered consonance rather than a rigidly shackled indexical mapping’.35

The psychic investment that we have in our body, its form and appearance is key to understanding the subjective experience of embodiment and hence needs to be reflected on in clinical and theoretical discussions of identity. The body is the primary site of inscription and meaning arising from external forces as well as internal, unconscious ones. We suggest that understanding the breadth of meaning and function that is subsumed under ‘transgender’ as an identity referent is helped if we think not only in terms of societal ‘gender’ ascriptions but also in terms of the subjective experience of embodiment, of the body’s unconscious identifications and hence the psychic function of the modification of the body.36 This is important because the representation that we have of our bodies in our minds is profoundly shaped by the projections of others—often early attachment figures—onto our bodies. In order to protect autonomy, it is important to disaggregate the beliefs and desires that belong to the individual wishing to transition from those that they think belong to them but may in fact be better understood as serving other unconscious functions such as, for example, appeasing another person’s desires, as we have illustrated with Sam’s case, or that may be unconsciously felt by the individual to be preferable to other less preferable alternatives (e.g., the person whose homosexual orientation is felt to be more laden with difficulty than coming out as transgender).

The unconscious aspects of identity deserve consideration because our sense of who we are—of our identity—derives in part from our early developmental experiences. Attachment research provides a further strand of evidence lending support to how early relationships unconsciously shape the development of the mind and what is referred to in psychoanalysis as the ‘internal world’.37 The internal world consists of prototypic schemas involving invariant dimensions of early affectively charged relationships (e.g., experiences of union and separation). In early life, heightened affective exchanges are psychically organising: they allow the baby to categorise and expect similar experiences. For example, a ‘negative’ experience of rejection may be internalised as a working model of an ‘ugly’-self-relating-to-a humiliating-other’. Once learnt, a relational working model unconsciously operates like a template for interpreting later events in a similar way; that is, it generalises. External relationships at any stage of the lifecycle may then trigger the affect associated with particular relationship constellations and the associated relational fantasies (e.g., ‘If I get close to another person, they will see my ugly self and humiliate me, so it’s best to keep others at a distance’). These mental representations of ‘self-affectively-interacting-with-other’ therefore contain both conscious and non-conscious cognitive and affective components deriving from significant interpersonal experiences with key attachment figures. Although the experiences that contributed to these schemas remain for the most part inaccessible to conscious memory because they are procedurally unconscious (i.e., are not registered in autobiographical memory), they nevertheless structure how we think and feel about ourselves and about others in the present. This is why, even though we may not be able to recall early events, we nevertheless continue to organise the present according to developmental models. In considering the significance of unconscious mentation to autonomous choice, we are therefore interested in the relevance of an unconscious internal world of relationships coloured by intense affects that influences our behaviour and decisions.

The ethical significance of reflective spaces for supporting autonomy

Our current understanding of the unconscious mind points to an important fact: ‘‘What is most meaningful in life is not necessarily encoded in words’’.38 This, we suggest, has important implications for how we might understand autonomy, well-being and consent. If, as psychoanalysis proposes, (1) we are formed by early relational experiences for which we have no declarative memories, (2) our present behaviour is informed unconsciously by repetitive relational and affective patterns that exert an impact on our experience of our self, of our desires and of the decisions we make, and if we are not self-reflectively aware of these patterns, then consent to medical interventions sought in order to instantiate physically our subjectively felt sense of who we are is potentially undermined.

Autonomy, we suggest, is enhanced by consideration of the implicit relational and affective templates that shape our experience of who we are and who we may feel that we ought to be and that underpins our decisions. Understanding of these patterns requires time and dialogue with others who can help us to decipher what is unconscious. The reflective space that psychoanalytically informed psychotherapy provides is the example, par excellence, of the kind of constructive dialogue that can support autonomy in decision-making due to its attention to conscious as well as unconscious processes. There is now accumulating evidence that psychoanalytic psychotherapy is an effective intervention for a range of mental health problems.39 40

A person is deemed to have the capacity to rationally choose iff she has at her disposal knowledge of all the facts relevant to the decision and the possible consequences for her of the potential decisions.5 We further propose that the condition of ‘being in possession of all available relevant facts’5 should include the specification that these ‘facts’ also involve consideration of possible unconscious drivers (e.g., wishes or unprocessed traumas). Once these unconscious influences become objects of conscious reflection, we can take steps to reduce or accommodate their effect on our behaviour and decisions. Although unconscious factors pose a threat to autonomy, the more we understand the extent to which we are unconsciously motivated and influenced, the better equipped we are to function autonomously. Becoming conscious of an unconscious wish or motive involves experiencing that wish or motive as one’s own. This makes it possible for us to assess whether we want to cultivate it or ignore it.

Importantly, our values may be unconscious or inarticulated. What we truly most desire may be opaque to us. Not only will psychoanalysis reveal facts about us, but it can reveal the nature of our values. This is important for most contemporary models of the doctor–patient relationship. It sits most comfortably with the liberal rationalist model which aims at normative dialogue to arrive at both the relevant facts for the patient but also what the patient should value. It is also important to shared decision-making where the patient must provide the values: those values may be unconscious. This might seem to provide a kind of ‘master self’ view: there is a rational self with values that the unconscious self is undermining, and we need to bring the motivations and influences of the unconscious self to the attention of the master self who will decide what to do with them. But the master self is also the result of these influences—there is a bootstrapping problem. The very values we have are the product of these influences and indeed may be unconscious.

Acknowledging the machinations of the unconscious reminds us of the limits to autonomy. Does this mean therefore that autonomy is an illusory state forever subverted by the unconscious? This requires some qualification. Autonomy is not an ‘all or nothing’ state. We are not making the absolute claim that engagement in a psychoanalytic process ensures that we reach at some point a fully autonomous state where we are no longer informed by unconscious drivers. The unconscious is a mental structure that continues to potentially exert its influence on our conscious decisions. Like a physical muscle that, if left unexercised, quickly reverts to its former state, our engagement with understanding the unconscious is not a once and for all process: it requires the regular exercise of this psychic muscle (i.e., ongoing self-reflection). If we exercise this psychic muscle, we stand to reap some benefits: we have an enhanced opportunity of identifying some of the pressures on our decisions that arise out of unconscious drivers and we can bring these more under conscious deliberation. The ‘benefits’ do not include the eradication of the unconscious—that is, an impossibility. To this extent, claims about autonomy in relation to the unconscious are always relative. We are making the more modest claim here that exploration of unconscious drivers supports the expansion of the range of autonomous functioning, not that it makes us autonomous in an absolute sense.

So far, we have argued that our conscious choices may be limited by powerful a priori motivations that can only assist us in decision-making through second-order reflection and evaluation. This process requires time. Time for self-reflection is not only important psychically, but it is also ethically significant because it supports autonomous decisionmaking given that the elaboration of unconscious meaning emerges piecemeal over time. This is one reason why unqualified acceptance of conscious claims can lead to unintended harms.

Clearly not all individuals who express the wish to transition are motivated by underlying psychological problems unconnected to gender identity as such, as was the case for Sam. We are therefore not suggesting that requests for transitioning should be regarded suspiciously. Rather, we are suggesting that cases such as Sam’s caution us to consider how our medical protocols can best safeguard spaces for reflection should what appears on the surface to be a well-thought-out decision be just the tip of an iceberg of meaning and psychological needs that will not be successfully met by transitioning.

Sam’s case underscores the complexity of assessing autonomy and one’s own assessment of one’s interests when we factor in systemic and intrapsychic unconscious pressures on self-perception and identity development. Sam appeared to have been driven primarily by a wish to claim a space in his parents’ mind (especially his mother) that he felt was occupied by his deceased brother. He unconsciously resolved to do this by identifying as a boy and then asking to transition so that he could replace his brother. Even though the family was not consciously coercing Sam to change gender, it could be argued that there was an unconscious investment in supporting the gender transition so as to reclaim their lost son. Systemic pressures can thus potentially function to enforce conformity to unconscious needs that act against the person’s best interests.

Sam’s case can, and indeed should, be countered by cases that reveal that transitioning was, all things considered, better for the person. Such cases are important reminders that medical transitioning can enhance well-being and be an expression of autonomy. However, the fact that this can be the outcome of transitioning for some is not an argument against a thorough exploration of the motivations for wanting to transition so as to ensure that the decisions taken can be said to be substantially autonomous and substantially independent from controlling forces such that the person ‘…is free of controls exerted either by external sources or by internal states that rob the person of self-directedness’.21 Proscribing such exploration sets up a climate that can unwittingly promote potential harm rather than reduce it, as Sam’s example illustrates. Sam’s case illustrates the operation of the relationship between external and internal pressures on decision making about transitioning. His family was driven by their own grief to pressurise Sam into transitioning. This external pressure, however, is not recognised as such consciously by Sam. It is unreflectively internalised and takes on a life of its own in the idiosyncratic prerogatives of his internal world, for example, his own unconscious longing to be loved by his parents and to replace his brother and the guilt this provokes.

Affirmation of that which is not in fact the truth is undermining of autonomy and likely to frustrate interests. As Beauchamp and Childress21 underline, if a patient holds a false belief about their condition, their decision about treatment is compromised. Full autonomy requires not only presentation of medical facts but that the patient holds rational beliefs about their condition, the possible interventions, their risks and benefits, but importantly themselves and their psychic nature.5 A decision to transition cannot be an instantiation of autonomy if it is based on a false narrative that prevents the person from accessing the help and resources appropriate to the state that actually undermines their well-being. The individual’s current wishes, no matter how strongly felt, are not always a reliable indicator of what will enhance well-being. By contrast, engagement over time in a process of psychotherapy may open up new possibilities for greater autonomy and well-being than that potentially afforded by (premature) transitioning.

To be genuinely autonomous is to understand oneself both at the conscious and unconscious level. That said, it is important to not allow the re-entry of old-style paternalism and the imputation of desires and values at an unconscious level on the patient. It must be the patient who does the work and identifies these unconscious properties, with the assistance of the therapist. It is also important that patients can choose options which are ultimately less than the best. Mill described experiments in living as the best way to achieve individuality (autonomy). Maybe the best we can hope for is to live in different ways, reversibly, before we choose a final path. Freedom is, in part, taking responsibility for living with your choices.