Beyond Gender Dysphoria: Identity, Embodiment, and Development in the Psychodynamic Psychotherapy of a Gender-Questioning Adolescent. An Interpretive Psychodynamic Case Study

1. Introduction

Adolescent gender dysphoria is commonly understood through competing medical, developmental, and sociocultural explanatory frameworks (Kenny, 2025). Less attention is given to the meanings that gender identity acquires as it becomes integrated into the developing personality. This paper interrogates how the transgender identity became psychologically elaborated through embodiment, family relationships, shame, competence, autonomy, and emerging desire. It also explores the therapeutic relationship, transference and countertransference phenomena, the role of epistemic trust in the relationship and the emergence of a concept I describe as psychological sovereignty, which became the core striving for this adolescent.

2. Materials and Methods

This case study is based on 22 months (comprising 50 recorded individual psychotherapy sessions) with “Conan”, a self-declared female-to-male transman who was 16 at commencement and 17 approaching 18 during the later material, supplemented by separate parent interviews, family-related communications, and contemporaneous clinical formulations. The material was not collected as research and no standardized outcome measures were administered. It is presented as an idiographic, interpretive case study. Identifying details have been altered, and the pseudonym “Conan” is used throughout. The account is written from the therapist’s clinical perspective and therefore reflects the inevitable selectivity of therapeutic attention, memory, process notes, and countertransference.

Three epistemic levels are distinguished wherever possible. First, clinical observations refer to reported events, recurring speech patterns, and changes evident in sessions. Second, clinical inferences concern patterns reasonably suggested by those observations, such as Conan’s recurrent intolerance of dependence or the family’s triangular communication. Third, psychodynamic hypotheses, for example, that contempt may protect against disowned helplessness, are proposed as provisional meanings rather than established facts. This distinction is essential because psychodynamic interpretation generates plausible formulations; it does not demonstrate causal mechanisms.

The paper also avoids treating the family as the cause of gender dysphoria. Family organization is relevant because it shapes the emotional setting in which identity is declared, contested, and lived. Similarly, the exploration of sexual orientation is not an attempt to replace a transgender formulation with a lesbian one. It reflects the developmental fact that gender identity, erotic attraction, and relational intimacy are related but non-identical lines of development.

3. Case Presentation and Developmental Context

Briony is the eldest of three children in an intact family. She lived with both parents and two younger brothers aged 14 and 10. At referral she identified as male, used a masculine name, Conan, and pronouns outside some family contexts, wore a chest binder, and presented androgynously. No medical transition had occurred. She expressed a firm intention to pursue testosterone and surgery when legally and practically able to do so. She described marked distress about female secondary sexual characteristics and particular difficulty seeing her body while showering, which was sometimes undertaken in darkness, and hygiene was often severely neglected. She wore the same loose clothing for extended periods and slept in day clothes, including a large men’s jumper. These behaviours were reported by her mother and were not independently observed by the therapist although Conan would often arrive at her late afternoon appointments in pyjamas and with pungent body odour.

Conan was high functioning autistic (ASD Level 1), intellectually able, verbally fluent, and highly analytical. Sessions were characterized by extensive, detailed narratives, rapid associative links, sarcasm, political and philosophical commentary, and strong evaluations of the competence of peers and adults. She could describe cognitive “spiralling” and recognized that horse riding, writing, and psychotherapy helped her regain equilibrium. She was academically ambitious and future-oriented, a perspective she achieved during psychotherapy. At the outset, she was phobic of adulthood and assuming adult responsibilities, for example, refusing to learn to drive or get a casual job. Her interests extended far beyond gender. She was passionate about modern history and would often discuss historical events that she had been studying in class. At the same time, affect was often converted into argument. Interpersonal disappointment was more readily described as another person’s irrationality or irresponsibility than as hurt, loneliness, or need.

The available developmental history provided by mother did not include any unusual early gendered play; there was one early romantic attraction to a girl in year 6 and a shared kiss, but no childhood conviction or declaration of being male. The later identity narrative provided by Conan was nevertheless coherent and strongly held. Conan conceptualized gender dysphoria in biological and medical terms. She rejected explanations based merely on clothing, stereotypes, social treatment, or preference for male activities. In later sessions she stated that social passing would not be sufficient: even if strangers perceived her as male, she would still wish to change the sexed body. When imagining a life in which transition was impossible, she described suicide as a possible outcome. This statement required clinical risk assessment but should not be romanticized as proof of identity; it conveyed the degree to which continued female embodiment was experienced as intolerable.

Early in the treatment, I assessed Conan to be clinically depressed – she was endlessly in tears, unable to get out bed, and engaging in intense rumination about her gender distress. I referred her for consideration of antidepressant medication which was prescribed to almost immediate effect. Mood improved and gender fixation decreased after commencement of antidepressant medication, but bodily dysphoria and male identification remained prominent. The distinction is clinically important: improvement in depressive affect did not resolve the firmly held gender declaration but it created more psychological space in which other developmental concerns could emerge.

The presentation also included self-reported autistic and attentional features, including shutdown under emotional overload and a strong preference for precise explanations. A systematic cognitive style may have contributed to the preference for categorical definitions, biological accounts, and consistency between concepts and observable reality. Conan also had sensory sensitivities and an aversion to noise and physical touch. This was difficult for her parents who often sought to demonstrate physical affection which she rejected angrily.

This section may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation, and the experimental conclusions that can be drawn.

3.1. Family Structure and Relational Context

The family appeared cohesive in the sense that both parents remained invested and Conan remained embedded in everyday family life. Yet the parental subsystem was structurally unstable. The mother, Kate, understood parenting as active leadership and limit-setting. She was conscientious, practically involved, and persistent in seeking connection. From Conan’s perspective, however, her questions about appearance, hygiene, friendships, study, and gender often felt like surveillance. Her attempts to engage were frequently experienced as demands that Conan account for her internal experiences before she was ready to do so.

Conan’s repeated rejections injured Kate. One example described by Mother involved her entering Conan’s room while she was lying on her bed. Mother tweaked her toe affectionately and Conan shouted at her to stop “toe raping me”. Mother was hurt and shocked and withdrew immediately. Thereafter, Mother resolved to wait “until Conan comes to me.” This withdrawal was not reported as punitive; it appeared to be a protection against further rejection. It was experienced with relief by Conan. The resulting pattern was recursive: Kate’s anxiety led to pursuit and stronger limits; Conan experienced greater control and withdrew or became contemptuous; Kate felt excluded and intensified her efforts or retreated hurt. Each person’s attempt to solve the problem confirmed the other’s fear.

The father, Max, who was a functional alcoholic, occupied a different position. Conan described him as intellectually didactic and prone to extended lectures on political, financial, and moral subjects like those with which she regaled the therapist during sessions. His history included regular alcohol use (although the material did not support a formal diagnosis of alcohol abuse disorder) and periods of emotional unpredictability and unavailability. In the family’s organization, Max often acted as an anxiety regulator. When Kate imposed consequences, he softened them, restored familiar rituals, apologized, or offered small compensatory comforts. These actions expressed affection but weakened the parental alliance. Kate was left as the restrictive parent, while Max became the parent who relieved tension. The conflict was therefore not simply parents versus child; it involved an executive subsystem divided over how much disappointment and distance could be tolerated. Kate often felt abandoned by Max in her parenting. She said that Max “could not stand seeing the kids upset and wanted to be their friend rather than their father.”

The sibling subsystem was also drawn into the conflict. Brian, the middle child, shared humour and a masculine sibling bond with Conan (e.g., they would refer to each other as “bro”). Brian reportedly told his mother that he sometimes agreed with Conan to preserve closeness but reassured her he was not following in the gender transition footsteps of his sister. This placed him in the position of emotional intermediary between Conan and their parents. Family members frequently spoke about one another through third parties, and information travelled rapidly across subsystem boundaries. The family thus combined diffuse informational boundaries with rigid emotional positions.

From a structural family therapy perspective, gender became a high-intensity arena in a wider negotiation over who governed Conan’s body, privacy, sleep, study, phone, screens, employment, and future. This does not necessarily make the gender declaration a family symptom. It means that a pre-existing developmental conflict over authority became concentrated around gender because gender decisions carried exceptional symbolic and practical consequences. As Conan approached adulthood, the family required a transition from unilateral parental management to negotiated interdependence. The parents’ difficulty making that shift, and Conan’s tendency to equate negotiation with surrender, maintained the impasse.

Despite the conflict, several protective features remained. Kate continued to seek repair. Max preserved affection, even when his conflict-avoidance was structurally unhelpful. Conan retained meaningful relationships with both parents and both brothers and could identify valued family qualities. The family was not emotionally empty; it was caught in a mutually escalating struggle over closeness and control.

3.2. Personality Organization and Core Psychodynamic Formulation

Conan’s personality was intact other than the single depressive episode and clinically significant gender dysphoria. Reality testing was intact. She displayed sustained attention to external detail, complex social reasoning, humour, future planning, and the capacity to revise at least some opinions. Identity was not globally diffuse. She had a stable autobiographical narrative, coherent values, recognized interests, and a persistent gender formulation.

Several defensive operations were recurrent. Intellectualization transformed emotional experience into analysis. Rationalization converted wishes and fears into arguments about logic, biology, or morality. Devaluation and sarcasm helped Conan distance herself from people experienced as incompetent, intrusive, or dependent. At times, idealization and devaluation narrowed the field of perception, although neither was absolute. Conan could later acknowledge that a disappointing counsellor remained “nice,” that parents could be at the same time loving and difficult, and that friends could have strengths alongside serious limitations.

The internal relational world appeared organized around three recurring positions. The first was an intrusive or critical authority: an adult who assumed the right to define reality, question Conan’s legitimacy, or demand emotional access. The second was a competent, self-governing self: rational, disciplined, physically strong, morally accountable, and not dependent on rescue. The third was a helpless or immature other who procrastinated, sought easy solutions, failed to use advice, or expected others to organize her life. The emotional intensity directed toward the third position suggested that helplessness was not merely disliked; it was experienced as psychically dangerous.

One possible psychodynamic hypothesis is that contempt defended against identification with vulnerable self-states. Conan’s outrage toward a university-aged friend illustrates the pattern. The friend procrastinated, remained on a laptop while Conan visited, sought advice without following it, and considered antidepressant or stimulant medication as a solution to her disorganization. Conan’s complaint was partly realistic: the friend was inconsiderate, continuing to look at her computer while Conan waited for her attention, and the friend’s encounters with unsafe males involved genuine risk. Yet the sustained ferocity of Conan’s response exceeded the immediate events. The friend became the embodiment of passivity, poor boundaries, dependence, and failure to act. Conan repeatedly demanded that people “do something.” This may have externalized an internal prohibition: never become a helpless person whose needs can be dismissed, controlled, or used against them.

Shame was the affect most clearly visible beneath this competent self-organization. Early material included spiralling questions about being good enough and lovable, especially following parental statements about transition and future relationships. Mother had told her that no one would love her if she transitioned. The competent self may therefore be understood partly as adaptive narcissistic repair. Mastery, intelligence, moral clarity, and bodily strength (Conan worked out with her father) offered protection from the feared position of defectiveness. This was not grandiosity in the sense of pervasive fantasy or impaired reality testing. It was a vulnerable self-esteem system in which competence carried unusually high regulatory value.

Masculinity became associated with many attributes of the ideal self: strength, action, independence, rationality, responsibility, and physical solidity. This observation does not establish that male identification arose from admiration of these qualities. It suggests that, once male identity was established, masculinity became a symbolic container for qualities Conan valued. Conversely, unwanted femininity became linked not only to the sexed body but also, at times, to dependence, exposure, passivity, and maternal identification. This formulation must remain tentative because Conan did not simply reject all women or all feminine qualities. She respected competent women, like her modern history teacher, and criticized men who violated her standards like some of her male school peers. The more accurate polarity was agency versus helplessness, even though that polarity became partially gendered in her symbolic life.

The central conflict can therefore be expressed as attachment versus self-governance. Conan wanted recognition and reliable attachment but feared that needing another person would grant that person authority over her mind. This conflict appeared in family relationships, friendships, and therapy. It also shaped the meaning that gender transition acquired. The question was not only, “Can my body become male?” but, “Can I become the person who has final authority over what my body and life mean?”

3.3. Embodiment and the Meaning of the Transgender Declaration

“Trans and other people tell you, you don’t need dysphoria to be trans. Yes, you do. Why else would you transition if you’re not in extreme stress...?”

Conan’s description of gender dysphoria supports taking her gender dysphoria as an embodied experience rather than reducing it only to a social role. Female secondary sexual characteristics, menstruation, showering, and the prospect of permanent female anatomy were described as deeply aversive. Poor hygiene and showering in darkness may be understood as avoidance of bodily exposure. They could also reflect depression, sensory sensitivities, adolescent oppositionality, or self-neglect. A psychodynamic reading adds—but cannot prove—that care of the female body had become associated with attending to, and therefore acknowledging, a body experienced as alien.

Lemma’s (2015, 2021) work is useful because it resists treating the body as either raw anatomy or a free-floating representation. Psychic habitation of the body is an achievement. The body is experienced through the gaze of others, unconscious identifications, fantasies of belonging, and the person’s efforts to establish continuity between felt self and visible form. For Conan, the body was at once an unwanted inheritance, an object to conceal, a project to discipline, and the anticipated site of future transformation. Binding, loose clothing, weight training, protein intake, and plans for medical transition were not psychologically equivalent, but together they showed that the body was being actively worked upon. She stated

“People will also tell you that you don’t need to transition, like fully transition to be the opposite sex. It’s like, yes, you do. You can’t have a female body, be a woman and just be like, ‘Oh, I’m a trans man and I’m a man,’ but I’m not going to transition.”

This is important because Conan’s model is biologically essentialist. She distinguishes biological sex from gendered expression and believes a feminine man remains a man:

“ A man can wear feminine things... and he’ll still be a man because the biological sex of his brain and body align. “For me, being trans is very biological... I could be treated like a male by everyone, but I would still be dysphoric because it’s about female to male.”

The interest in weight training is therefore richer than simple imitation of a father or younger brother who were “bulking up.” Conan used improvised weights and sought heavier dumbbells and more protein. Interpretively, muscular development may have offered a concrete experience of efficacy: effort could visibly alter the body. It also supported a masculine silhouette and identification with her brother. A psychodynamic hypothesis is that strength-building transformed the body from an object that happened to Conan into an object on which Conan could act. The process may have been reparative even while remaining implicated in dysphoria.

The transgender declaration itself appeared to perform several functions without being reducible to any of them. First, it named a persistent experience of bodily incongruence.

“I am very certain and solid on the fact I’m trans... But I’m not, like, so attached to it either. If I woke up tomorrow... and there was no dysphoria... I’d be like, okay, well, maybe I’m not trans.”

Second, it provided a coherent category through which previously perceived personal defect could be understood as recognizable difference.

“If you’re not gonna be female, what are you gonna be? It’s like, well, I’m male. I need to be male. And that was sort of like the start of it...I would rather kill myself than live the rest of my life in something that is not a male body.”

Third, it established a boundary against parental definition. Fourth, it organized a future: adulthood, medical intervention, and bodily change could be imagined as a directed path rather than an indefinite continuation of distress. Conan did not conceptualize transgender identity primarily as membership in an identity category and separates transgender status from the label itself: “It’s a medical condition…”

To integrate these observations, I propose psychological sovereignty as an idiographic heuristic. Psychological sovereignty refers to the experience of being the legitimate author of one’s internal life—body, identity, values, desire, and future. Conan described it thus: “When I took control of my own appearance, I went very boyish very quickly.”

This differs from behavioural autonomy. An adolescent may remain financially and practically dependent while insisting that subjective experience is not subject to parental adjudication. In Conan’s case, gender transition appeared to become invested with this broader meaning of authorship.

…my parents say ‘whatever you do to yourself at 18, that’s not our fault’... But then they’ll keep inserting themselves into my business... So am I responsible for myself or not?”

Conan experienced her mother as unable to cope with her growing individuation. There are numerous examples throughout the transcripts of this striving for autonomy:

Maybe she can’t cope with the fact that, like, we’re gonna start to want independent things and... actually be functioning human beings in society… I’m nearly 18... I should be able to... at least choose when [my phone is] in my room… [Mum] was like, ‘You could be 12 or 22, as long as you’re under my roof, you don’t get freedoms in my house.’ That’s when I started making the Nazi jokes...”

This is not offered as the cause of dysphoria. It is a formulation of what transition came to signify within a family in which being known often felt equivalent to being governed.

Saketopoulou and Pellegrini’s (2024) challenge to the search for a pristine, pre-social core gender is relevant here. Their account is more radical than the present formulation, particularly in its treatment of trauma and gender acquisition, but it supports a shared commitment to developmental openness. Openness does not mean that every identity is equally likely to change, that declared identity should be disregarded, or that treatment should be indefinitely withheld. It means that identity remains alive to experience and that the therapist does not protect either the patient or the theory from new meanings. Conan’s certainty could be respected without requiring the therapist to regard every dimension of future embodiment, sexuality, and relationship as already settled. This stance also avoids a false dichotomy between authenticity and function. A declaration can be authentic and simultaneously regulate shame, consolidate boundaries, organize hope, and facilitate separation. The fact that an identity carries defensive or relational meanings does not make it false. Conversely, respect for identity does not render it exempt from psychological enquiry.

3.4. Gender Identity and the Open Question of Sexual Orientation

Sexuality was strikingly less developed in the treatment narrative than gender identity. Conan spoke extensively about body, pronouns, transition, peers, competence, and family conflict, but initially offered little material about crushes, erotic fantasy, romantic longing, or actual relationships. This absence is an observation, not evidence of repression, homosexuality, heterosexuality, or asexuality. It may reflect the priorities of treatment, lack of experience, privacy, dysphoric avoidance of sexual embodiment, or the ordinary unevenness of adolescent development.

The possibility that Conan might later understand herself as lesbian had been raised in supervision because the patient was natally female, had not experienced romantic relationships, and had adopted an increasingly masculine presentation. That hypothesis requires substantial caution. Masculine presentation is not evidence of lesbian orientation, and a future lesbian identity cannot be inferred from the current material. Nor would discovery of same-sex attraction, in itself, disconfirm a transgender identity; a transmasculine person attracted to women may understand that attraction as heterosexual, queer, or otherwise.

Two anecdotes are nevertheless developmentally informative. When Conan was 15, a boy in her year at school expressed interest in dating her. Conan acknowledged attraction to this boy but ultimately turned him down, explaining that if she dated anyone, it would have to be in the role of the male and she realized that her classmate had the opposite expectation.

In the second, Conan described Micah, a fictional cowboy character in a computer game, as “hot” and as her “husband.” She named her orthodontic retainer Micah and joked to her mother at bedtime that it was “time to put Micah in my mouth.” The remark may have been a deliberate sexual joke, playful provocation, adolescent humour, or some combination. It should not be mined for hidden certainty. Its importance is that it was one of the first spontaneous expressions of attraction to an object rather than identification with one.

Freud’s distinction between identification and object choice remains useful if applied without heteronormative prediction. Much of Conan’s earlier material concerned being male and embodying valued masculine attributes. Micah introduced wanting a male figure. The fictional object was safe: he could not reject, intrude, or demand reciprocal vulnerability. The joke communicated emerging sexuality to the mother while preserving deniability through humour. In Winnicottian (1971) terms, the game character and named retainer occupied an intermediate area of play where fantasy, embodiment, and relationship could be explored without the risks of an actual encounter.

This vignette therefore supports a modest developmental conclusion: identity, agency, and erotic desire were not developing at the same rate. It does not resolve Conan’s future sexual orientation. The clinically appropriate position is neither to assume persistence nor to anticipate lesbian identification, but to make room for erotic development to become thinkable without recruiting it to prove or disprove gender identity. Longitudinal evidence concerning persistence and change is considered in the Discussion below.

3.5. The Therapeutic Relationship, Epistemic Trust, and Denigration

The transference was organized less around the therapist’s gender than around authority, recognition, and influence. Conan appeared to ask: Can another mind understand me without taking possession of my experience? Early in treatment, adults were often represented as people who lectured, reassured superficially, or imposed an interpretive framework. The therapist’s first task was therefore not a deep interpretation of gender but the establishment of a setting in which thinking with another person did not equal submission.

The therapist adopted a consistently curious and non-coercive stance. Preferred name and pronouns were respected but rarely used, bodily distress was not disputed, and no predetermined identity outcome was suggested or imposed. At the same time, the therapist did not simply echo Conan’s conclusions. She asked about affect, relationships, contradictory experiences, and the meanings of events. This combination appears to have supported both alliance and exploration.

Fonagy and colleagues’ (2015) concept of epistemic trust sharpens the formulation. Epistemic trust is the capacity to regard communication from another person as relevant, generalizable, and potentially useful to the self. Conan was not globally closed to learning; she sought information actively. The difficulty concerned interpersonal knowledge delivered by an authority whose intentions might be intrusive. In such circumstances, mistrust protected autonomy but also restricted the capacity to use relationships. Therapy may have helped restore selective epistemic openness: the therapist could offer a perspective without that perspective becoming a command.

Positive transference was often communicated indirectly. Conan continued attending, often bursting into my consulting room and starting to speak immediately, often with an expression of the kind, “Wow! Am I glad I have therapy today!” She spoke spontaneously, introduced new material, and contrasted the current therapy favourably with encounters with a former school counsellor and other psychologists. In one session she observed that she could discuss difficult matters with the current therapist in depth because, unlike other adults in her life, she “gets this sort of stuff.” This was evidence that the relationship mattered, although Conan did not idealize the therapist or express overt dependence.

Parent material complicated the picture. After one session, Mother asked Conan how her therapy had gone. Conan reportedly described the therapist as repetitive (“She asked me that before”), forgetful (“Is she losing it?”), or “the worst therapist,” despite appearing fully engaged in sessions and looking forward to appointments. This discrepancy could have several meanings. It might have reflected genuine dissatisfaction that was less safely expressed directly. It may have regulated dependence by reducing the therapist’s importance. It may have protected an identity of self-sufficiency: therapeutic gains could be experienced as self-generated rather than received from another. It may also have preserved family loyalty by preventing the therapist from becoming an idealized ally against her parents. These are hypotheses, not mutually exclusive conclusions.

The therapist’s countertransference included admiration for Conan’s intelligence, frustration at endless contemptuous monologues about her parents, teachers and friends, concern about transition decisions, and potential pressure to choose between affirming and skeptical positions. The major technical achievement was the refusal to become either a compliant validator or a corrective parent. The therapist maintained what Bion (1970) described as negative capability—the capacity to remain psychologically alive in the presence of uncertainty without premature closure. Rather than deciding whether Cody’s transgender identity represented biological reality, developmental adaptation, defensive organisation or some combination thereof, therapy consistently returned to exploration.

This stance required considerable emotional discipline. Patients seeking certainty often evoke corresponding wishes within therapists to provide certainty. Cody’s intellectual sophistication, articulate arguments and evident distress could easily have recruited either ideological affirmation or interpretive reductionism. The therapist consistently resisted both positions. At times, however, the therapist’s supportive reflections risked reinforcing Conan’s superiority, for example, by agreeing too readily that peers were immature because Conan had done exceptional work on herself. Such interventions strengthened the alliance but could bypass the personal meaning of helplessness. A deeper intervention occurred subsequently that linked the external complaint to internal vulnerability (“What happens when you need help, procrastinate, or fear not knowing what to do?”).

The therapist also needed caution in discussions with the mother whose preferred explanation that Conan “looked like a butch lesbian” and was probably lesbian (a preferred outcome) risked aligning with the mother’s preference that Conan be lesbian rather than transgender and converting an open developmental question into a competing identity assignment. A neutral formulation was offered that noted that masculine presentation, gender identity, sexual orientation, and bodily development had not yet achieved their final adult integration.

Overall, the treatment relationship offered an experience of authority compatible with autonomy. Conan could use another mind without having to idealize it, submit to it, or destroy it. That relational achievement may be more fundamental than any single interpretation.

3.6. Therapeutic Progress

The strongest evidence of progress was not change in gender identification. Conan continued to identify as male, remained distressed by the female body, and intended to pursue transition. The relevant question is whether the personality carrying that identity became more flexible, reflective, and relationally capable.

Several changes were observable. The thematic field widened. Early material was heavily organized around gender legitimacy, parental opposition, and cognitive spiralling. Later sessions included career planning, school, politics, friendships, competence, safety, boundaries, exercise, and attraction. Gender remained important but no longer monopolized the therapeutic space. This widening may indicate greater self-cohesion: the patient could bring more of the personality into the room.

Conan also developed firmer interpersonal boundaries. In the conflict with the university-age friend, she recognized that friendship required reciprocity and that concern for another person did not oblige her to complete the other’s tasks or tolerate being ignored. Leaving an unsafe or disrespectful situation represented increased agency. The progress was incomplete, however. Boundary-setting remained entangled with contempt, certainty about others’ diagnoses and medication needs, and difficulty tolerating developmental differences. The therapeutic task was therefore to preserve the boundary while softening devaluation.

There were signs of greater capacity for ambivalence. Conan could describe the former counsellor as kind yet disappointing, parents as caring yet intrusive, and friendships as valuable yet limited. She could also identify that some earlier tolerance of poor treatment had changed. These developments suggest increased integration of self and object representations in Kernberg’s (1975, 1984) sense, although the evidence remains clinical rather than standardized.

Mentalization appeared to improve unevenly. Conan was adept at analyzing motives but could become hyper-mentalizing—that is, overconfident about what others felt, needed, or diagnostically required. The therapist’s reflections were most useful when they shifted from certainty about the other to curiosity about Conan’s own affect. In Fonagy’s terms, progress involved not simply producing more explanations but increasing flexibility about the opacity of minds. The movement was from “I know exactly why this person behaves this way” toward “I know what their behaviour evokes in me, and there may be more than one account of them.”

Shame regulation also appeared to improve. Antidepressant treatment reduced depressive intensity, and psychotherapy provided a setting in which Conan could be angry, profane, doubtful, and imperfect without being humiliated. The ideal competent self remained prominent, but vulnerability could occasionally be acknowledged without immediate collapse into self-attack or restoration through superiority.

The treatment also facilitated a developmental shift from identity defence toward identity inhabitation. Earlier sessions required repeated demonstration that Conan was “really” trans and that a biological account was logically consistent. Later sessions suggested less need to argue continuously. The identity remained firm, but the person around it became more visible. This is best described as consolidation rather than validation of any particular future course.

Important difficulties persisted. Hygiene remained concerning. Bodily care continued to be compromised. Contempt and rigid moral judgement threatened peer relationships. Sexuality and intimacy were only beginning to emerge. Family conflict had not been resolved, and the parental subsystem remained divided. Suicidal statements in relation to blocked transition required ongoing assessment, regardless of whether they were acute, conditional, or existential in quality.

4. Discussion

Taken together, the clinical material supports a distinction between explaining the origin of a transgender declaration and examining the meanings it acquires within development. Conan’s dysphoria was consistently described as concrete and bodily; psychodynamic enquiry added a second level of understanding by tracing how embodiment became linked with authorship, shame, competence, separation, and anticipated adulthood. These meanings neither proved nor disproved the identity. They described how it was lived within one developing personality.

Blos’s (1967) second individuation provides the broad developmental frame. Conan’s struggle was not only to separate from parents but to retain attachment while becoming the owner of a private mind. The family’s structural instability intensified the challenge: maternal pursuit made separateness feel endangered, while paternal anxiety reduction made boundaries negotiable and left the mother isolated. Gender became the most consequential site of this struggle because it involved name, body, medical authority, and future adulthood.

Kernberg’s account of identity integration is useful here primarily as a structural contrast. Conan showed no evidence of global identity diffusion, impaired reality testing, or pervasive primitive defences. The clinically relevant issue was instead the rigidity with which a coherent self-representation could be defended when self-esteem was threatened. Therapeutic progress therefore involved greater capacity to hold mixed representations of self and others without surrendering a stable sense of self.

Lemma’s work on embodiment helps conceptualize this development without reducing it to a dispute about whether Conan’s perception of the body was “correct.” The relevant question is how the body could become increasingly habitable. Concealment, binding, weight training, and anticipated transition represented different ways of managing a body that was experienced as both alien and modifiable; across treatment, bodily action increasingly became a vehicle for agency rather than only avoidance.

Saketopoulou and Pellegrini’s emphasis on developmental openness complements this view. In this case, openness did not mean withholding recognition or assuming that identity would change. It meant allowing the meanings of masculinity, dependence, sexuality, and separation to remain available for further development. Respect for the declaration and curiosity about its unconscious and relational meanings were therefore treated as compatible rather than opposing positions.

Psychological sovereignty is best retained as an organizing hypothesis rather than a general theory. It offers a concise way of linking Conan’s recurrent concern with authorship across body, family rules, peer dependence, and therapeutic influence, while leaving room for alternative formulations grounded in attachment, neurodivergence, minority stress, self-psychology, or ordinary adolescent individuation.

The course of identity in longitudinal research is relevant but cannot determine individual formulation. Older childhood cohorts included many children who would not meet contemporary referral patterns and reported substantial variation in later identity and sexuality (Steensma et al., 2011). More recent cohorts of socially transitioned children and clinic-referred adolescents show much higher stability over available follow-up periods (Olson et al., 2022; Metzger et al., 2026). Hormone continuation was also high in the Amsterdam cohort (van der Loos et al., 2022). Prospective medical cohorts have reported average improvements in appearance congruence and psychosocial functioning (Chen et al., 2023), while the field continues to debate study design, selection effects, adverse events, and the absence of long-term comparative data (de Vries & Hannema, 2023; Doyle et al., 2023). These findings differ because samples, ages, interventions, definitions, and follow-up periods differ. The justified conclusion is not that identity is inevitably stable or inevitably fluid, but that developmental trajectories cannot be inferred from slogans or from older findings detached from their populations.

The late emergence of the Micah vignette suggests three partially independent developmental lines: identity (“Who am I?”), agency (“Can I author my life?”), and desire (“Whom do I want?”). In Conan, identity was articulated first, agency became increasingly visible through boundaries and bodily discipline, and erotic object choice appeared later and indirectly. This asynchrony may be clinically useful beyond gender-related cases. Adolescents can achieve conceptual certainty before emotional integration, and a strongly declared identity may coexist with limited experience of intimacy. Therapy should neither use emerging attraction to invalidate identity nor assume that identity has settled every question about desire.

The treatment also supports a distinction between affirmation and exploration. Respecting Conan’s name, pronouns, and reported dysphoria provided relational safety. Exploration enlarged the field of meaning. These aims were complementary. Exploration becomes harmful when it is a covert attempt to direct the patient toward a preferred identity; affirmation becomes psychologically thin when it requires the clinician to stop thinking. A psychodynamic position recognizes subjective authority while preserving curiosity about how the patient’s experience is organized.

Fonagy’s epistemic framework helps explain why the therapeutic stance mattered. The central issue was not lack of reasoning capacity but whether knowledge offered by another person could be used without being experienced as an intrusion. A non-retaliatory, non-coercive relationship allowed criticism and selective dependence to become more tolerable, making communication increasingly usable rather than something that had to be obeyed or rejected.

These formulations have direct clinical implications: treatment should move beyond repeated debate over the truth of the gender declaration and address embodiment, bodily care, shame, dependence, intimacy, family structure, and risk in ways that preserve both autonomy and developmental openness. Because these priorities require greater technical specificity, they are set out in the following section.

4.1. Future Therapeutic Directions and Clinical Implications

The next phase of treatment should preserve the exploratory stance while becoming more technically focused. Gender need not be the subject of every session, but it should remain available whenever Conan brings bodily distress, anticipated treatment, social recognition, or fear of an unlivable future. The therapist’s task is to prevent two forms of foreclosure: treating the declared identity as the complete explanation of all distress and treating psychodynamic meaning as evidence that the identity is mistaken.

A priority is the recovery of ordinary bodily care. Hygiene problems are clinically significant irrespective of gender formulation. The therapist should assess what occurs before and during showering: visual dysphoria, disgust, sensory discomfort, depressive inertia, executive dysfunction, fear of menstruation, or the experience of being forced to attend to unwanted anatomy. Practical strategies such as dim lighting rather than complete darkness, brief showers, selected clothing changes, skin care framed as comfort rather than feminization can be developed collaboratively. Such work communicates that respecting dysphoria does not require abandoning the body that presently exists.

A second priority is integration of agency and dependence. Conan’s growing boundaries are a major achievement, but they remain vulnerable to hardening into contempt. Sessions can distinguish refusing exploitation from repudiating everyone who struggles. When Conan criticizes a passive friend, the therapist can validate the realistic grievance and then enquire into the feared self-position: What would it mean to be the one who cannot organize, needs encouragement, or takes medication? The goal is not to make Conan more accommodating but to loosen the equation between need and worthlessness. Such issues can be brought into the transference, a process that may support the deepening of epistemic trust because Conan can discover that another mind remains available after criticism. It also protects against covert idealization and against the therapist defensively proving her competence.

Third, the treatment should increasingly address erotic development and imagined adulthood. The Micah anecdote provides an opening but not an interpretation to be imposed. The therapist might ask what qualities make the character attractive, what Conan imagines in the word “husband,” and how being desired is imagined in relation to the current and future body. Attraction to women should be equally thinkable. The clinical aim is to facilitate object choice and intimacy, not to classify orientation prematurely or use desire as a referendum on gender.

Fourth, family intervention should target structure rather than ideological agreement. Kate and Max require a more coherent parental position on household expectations while accepting that Conan is approaching legal adulthood. They can agree on safety, finances, school participation, shared responsibilities, and respectful communication without presenting a united campaign against identity. Max needs help tolerating Conan’s disappointment without immediately reversing limits; Kate needs support expressing concern without interrogating or pursuing. Brian should be removed from the role of messenger and permitted a sibling relationship unburdened by mediation.

Finally, risk assessment must remain explicit. Conan’s statement that transition impossibility could lead to suicide should be revisited periodically and assessed for intent, planning, access to means, temporal proximity, and protective factors. The therapist should neither dismiss such statements as rhetorical nor treat them as proof that a particular intervention is mandatory. Careful risk formulation can coexist with developmental and medical uncertainty.

Across these tasks, progress should be evaluated through multiple domains: safety, bodily care, capacity to use relationships, flexibility of self-representation, tolerance of uncertainty, educational and social functioning, and the ability to make consequential decisions without coercion or defensive urgency. The desired outcome is not a predetermined gender endpoint. It is a young adult increasingly capable of inhabiting the body, relationships, work, sexuality, and identity that emerge over time.

4.2. Limitations

This is a single, therapist-authored case study and cannot establish causal relationships or population-level conclusions. The clinical record was not created for research; material was selected through therapeutic attention and retrospectively organized into a psychodynamic narrative. No independent raters, structured personality assessment, or standardized outcome measures were used. Statements about improvement therefore refer to observed changes in discourse, thematic range, boundaries, and relational capacity rather than quantified effects.

The account incorporates parent interviews as well as individual therapy. This provides valuable triangulation but also introduces competing perspectives and confidentiality complexities. Parent reports of hygiene, family conversations, and denigration of the therapist may be accurate, partial, or shaped by parental distress. They are treated as data about both behaviour and family meaning, not as objective adjudication.

The formulation is theoretically selective. Object relations, developmental psychoanalysis, structural family therapy, embodiment, and epistemic trust illuminate different aspects of the material, but other frameworks could produce different accounts. Minority stress, neurodevelopmental characteristics, peer context, and broader cultural influences are less fully developed here. The construct of psychological sovereignty is as yet idiographic and unvalidated.

The developmental course remains incomplete. Conan was 17 during the later material and had not yet entered sustained adult intimacy or completed decisions about medical transition. The paper cannot predict persistence, detransition, regret, satisfaction, or sexual orientation. The Micah vignette is especially vulnerable to overinterpretation and is included only as an example of emerging erotic representation.

Finally, the manuscript is limited by the risk of reproducing the very certainty it critiques. Psychodynamic language can make hypotheses sound authoritative. For that reason, observations, inferences, and interpretations have been differentiated throughout, and alternative meanings are retained where the record permits them.

5. Conclusions

Conan’s psychotherapy did not reveal a hidden explanation for gender dysphoria or settle the future of identity. It showed instead how a firmly held male identification became increasingly inhabited within a wider developmental process involving embodiment, competence, shame, separation from parental authority, and authorship of an adult future.

The treatment’s most important changes occurred around identity rather than in it. Conan’s thematic world broadened, interpersonal boundaries strengthened, representations of others became somewhat more ambivalent, and the therapist became usable without being idealized. The male identification remained stable. Psychodynamic progress therefore cannot be defined as movement toward or away from gender transition. It is better understood as increased freedom to think, feel, relate, and decide without every experience being recruited to defend a precarious self.

The case also illustrates the developmental value of uncertainty. Current longitudinal evidence suggests substantial stability in many contemporary cohorts, but it does not eliminate individual variation or answer how identity will integrate with adult embodiment and desire. Developmental openness is not indecision imposed by the therapist. It is the preservation of psychological space in which identity can acquire new meanings without being treated as either false or untouchable.

Adolescence is not simply the period in which identity is discovered. It is the period in which identity becomes psychologically inhabited through the body, individuation, agency, and intimacy. Psychodynamic psychotherapy contributes not by explaining identity away, but by helping the young person become increasingly capable of living it as the author, rather than merely the object of other people’s certainty.

Across gender, family, vocation, art, and therapy, Conan’s recurring demand could be summarized as: “Allow me to be the authority on the experience of being me.” Psychodynamic psychotherapy contributed by making that authority increasingly compatible with reflection, relationship, and uncertainty rather than by determining the identity outcome.