Over the past seventy years the wish to change one's sex has been recognised and exploited by medical professionals, including endocrinologist and surgeons, who gave their patients the means of transforming their fantasy of gender change into reality. Then the discovery, or invention, of 'transsexualism' changed the way we regard gender and contributed to the fantasy that people can change gender with medical assistance in order to become authentically themselves.

Most people today have a limited understanding of the hidden beliefs that shape trans feelings. There seems to be little recognition of the possibility that emotional difficulties experienced during childhood and adolescence can give rise to trans feelings and the wish to change gender. I will therefore explain the role of the unconscious in shaping one's identity and why this should be placed at the heart of professional practice with trans children. My approach is informed by psychoanalytic theory, which offers a good model for understanding the psyche and the origins of disturbed feelings.

I will consider the experiences of children and young people who present with trans feelings in a way that does not deny the reality of their current feelings but offers a better way of understanding their emotional development and the meaning of their troubled feelings. I do not regard members of the trans community as victims of an oppressive society. Instead, I take a developmental approach to their difficulties and recognise the need for an ethical stance that values diversity in personal self-expression.

It is not possible to explore the inner world of children and young people without an understanding of the crucial learning about relationships that happens during the first five years of life. This is a stage which has a profound effect on the child's emerging personality and eventually on gender identity. The hidden beliefs that shape trans feelings almost certainly have their origins in this stage of development.

During this stage the parental function includes 'holding' the child both physically and emotionally - in the sense of giving affection, emotional support and stimulation and providing controls that keep the child safe. 'Separation anxiety' is a normal part of the next stage of development. Parents therefore need to support their child in gradually becoming more self-reliant, while recognising the child's natural anxieties about separation from them. If all goes well in this process the child's growing sense of 'Self' becomes apparent and begins to be expressed in various ways through play and verbal interaction with others.

When the child goes to nursery, and later on to school, he or she will obviously face new experiences and opportunities for learning. Girls and boys are then beginning to show differences in their personal presentation and demonstrate their capacity to self-designate as male or female. This is a time when parents should be helping their child develop a positive identity and offering support in managing their anxieties about dealing with new experiences. However, if family members have traditional ideas about boys and girls some children might develop anxieties arising out of over-rigid expectations within the family. However, in institutional settings official policies now encourage staff working with children not to impose gender stereotypes.

The infant who is growing up with both parents and has a secure home base is more likely to experience early attachments that provide the basis for healthy emotional development. However, an increasing number of children have a home life where the parenting is unsatisfactory in some way. Unfortunately, practical and ethical dilemmas regarding the need for state intervention often mean that the child's problems do not trigger an appropriate safeguarding or supportive intervention. In traditional communities the extended family may be able to give support to parents who are struggling and may also offer the child a lifeline. However, some children experience an early home life in which their real needs are not fully understood and met and the consequences of this only becomes apparent later on. In recent years the emotional and developmental difficulties of some children and young people have found expression in the provocative desire to change gender.

A child who is made to be prematurely self-reliant does not lose the urge to bond with another person. He or she does not therefore become a personality who can set appropriate boundaries in the way that a secure child would, who comes in the course of maturation gradually to love a parent as a person separate from him- or herself. The insecure child does not make relationships but does something very much more primitive. They use someone to provide them with pleasure and to ward off pain rather than by being their very Self. Should the person fail to provide pleasure they will withdraw emotionally. Withdrawals are often mistakenly regarded as breakdowns of relationships, but there has never been a relationship in the ordinary sense.

Support to the parents in helping them think about possible reasons for their child's difficulties is important but some parents may feel defensive and struggle to talk openly. Parents who have a limited capacity for understanding the complex mental life of their developing child may be people who have not had their own needs understood and met during infancy and childhood. However, a good therapist should keep in mind the possibility of an inter-generational cycle of emotional difficulties and try to engage the parents in constructive work. This may include the decision to frame the child's presenting problem as 'gender dysphoria'.

However, when we look inside the mind of a young person with problems we do not only find the echoes of his or her childhood experiences but also the reactions of the social environment and the whole world. Young people are not only unique individuals but also living reflections of their social and cultural environment. They may experience themselves as the authors of their own feelings and reactions and yet they are constantly enacting roles that are given to them by the wider society. Many enjoy being in the social world but may be too easily influenced by social media and ready to follow the latest fashionable idea.

The pernicious effect that poor emotional regulation is having in our society needs to be better understood. It is a factor in the inability to bring together the diversity of voices and create a collaborative response to the large rise in the number of children presenting as 'trans' in schools and referred for therapeutic help. 'Emotionalism' is highly regarded because it is truly egalitarian - we are all equally good at having feelings and like having our feelings validated. However, it can lead to judgements purely based on emotions - so whatever feels good must be right and whatever causes displeasure is wrong and must be challenged. This can even include challenging the scientific knowledge base underpinning the assignation of one's gender at birth.

On the other hand the person who is not self-centred but is concerned with dealing with the internal and external realities of his or her own life can only do so by containing emotions and showing self-reliance and fortitude. Unfortunately, this is often seen as suspect because it is about taking personal responsibility for managing one's difficult feelings. The rights and advocacy industries, with their over-emotional approaches to ethics, are the logical consequence of a simple emphasis on Selfhood. There is now a widespread belief that the only way to defeat arguments is to face them head-on and prove them false and the rigorous clash of argument will bring us closer to the truth. However, in the debate about society's response to trans children logical arguments are too often dismissed.

Some young people who identify as trans may have a tendency towards neurotic feelings. They may experience primarily one specific negative feeling such as anxiety, anger, or depression - or may experience several of these emotions. As a consequence they may respond emotionally to events and their reactions tend to be more intense than normal. They are more likely to interpret ordinary situations as threatening and minor frustrations as hopelessly difficult. These problems in emotional regulation can diminish a young person's ability to think clearly, make decisions and cope effectively with the normal stresses and strains of life.

Policy-makers are struggling to find a way through this impasse. The closure of the Gender Identity Development Service in London has been a step in the right direction. The next step is to provide a service for children and young people suffering from 'gender dysphoria' - that engages those suffering from anxieties about their physical attributes in finding a path towards a happier and more fulfilling life. Feelings about the body are problematic for many adults and it is not surprising that puberty can be a difficult stage of development for many young people.

The initial approach of the new service should be to explore the family dynamics and develop a deeper understanding of the psyche of the young person. The approach of the therapist working with the young person should be both supportive and insight-giving. The aim would be to engage the young person in therapeutic work as this would be an opportunity for him or her to discover the benefits of intimacy. This work would obviously require considerable skill and delicacy on the part of the therapist to do this in a way which is acceptable to the young person.

Therapy may help the young person understand that the physical changes associated with puberty will require them to make a mental adjustment and accept the challenges of growing up and moving towards adulthood. The therapist might find that negative feelings about their body and shame about their sexual organs are having an inhibiting effect on them and try to show the way towards a more relaxed attitude towards the body. The approach is based on the assumption that a mature adult knows that it is very pleasureable loving someone and being loved and, if the relationship includes physical intimacy, this can be very satisfying. Therapy may give some relief but the young person would also need love and kindness from family and friends to grow emotionally and to feel supported in taking responsibility for the particular identity they decide to assume.

Hilary Searing

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