The Imposition of Gender: Psychoanalytic Encounters with Genital Atypicality
Intersexed experience has been explored in only a handful of psychoanalytic reports, none of which examine the effects of this treatment paradigm . This paper presents the case of a woman who feared she is intersexed. The dynamics, transference, and countertransference configurations reenact the empathic failure implicit in her medical treatment and her family life, namely a caretaker’s preoccupation with the patient’s unusual anatomy, rather than her trauma.
Intersex conditions – the term refers to a range of anomalies of the reproductive system – are not especially rare; estimates are that 1 in 100 babies are born with genitals, genetics, or hormones that differ from standard male or female anatomy (Blackless, Charuvastra, Derryck, Fausto-Sterling, Lauzanne, & Less, 2000; Dreger, 1998). Physicians and parents faced with the birth of such a child must choose a treatment strategy that promises the best outcome given the current understanding of the complex genetic, hormonal, psychological, and social factors that form an individual’s sense of gender identity (Reiner, 1996).
Although this seems an inarguably sensible approach, a considerable, heated controversy hinges on the phrase, “current understanding.” Each of these factors has been reexamined in the last decade: the psychosexual neutrality of the infant, the effect of prenatal hormones on gender identity, the outcome of surgery on sexual function and sensation, and the impact of repeated medical procedures on psychological development and family functioning.Beginning nearly fifty years ago, Money argued that the stigma faced by children with atypical genitalia could be prevented by the immediate, authoritative assignment of the infant to a sex and surgical alteration of the genitals to remove any hint of ambiguity; about one of every two thousand children are currently treated in accordance with this paradigm (Blackless et al, 2000). Money theorized that children under the age of two were psychosexually neutral, so assignment was based on “projected genital appearance, sexual function, fertility, and the desires of the family” (Reiner, 1996). Because the success of this treatment was believed to depend on the conviction with which it was presented, any uncertainty by the parents as to the sex of the child was believed to threaten the parents’ attachment to the child and the child’s forming a gender identity to match the sex of rearing (Kessler, 1998). Thus, parents were assured that the assigned sex was the “real” sex even when this could not be truly ascertained. The argument that it is psychologically unbearable to know one’s genitals are neither typically male or female was the basis of parental and medical concealment of the reasons for the treatment from the child, although later surgical intervention was commonly required through latency and puberty (Natarajan, 1996; Preves, 1999; Nussbaum, 1999). Adoption of this paradigm was so complete that virtually all intersex individuals born since 1960 have been treated in accordance with it. Thus, although there may be 100,000 intersexed adults in the United States (Nussbaum, 1999), many are unaware of their condition.
This treatment approach has been based on extremely limited data, many of which have been subsequently challenged, and there is virtually no long-term follow-up research demonstrating its efficacy (Colapinto, 2000; Diamond & Sigmundson, 1997; Meyer-Bahlburg, Gruen, New, Bell, Morishima, Shimshi et al., 1996). Criticism raised about the existing paradigm by adults who were treated within it and advances in biomedical science, which are shedding new light on the complexity of sexual differentiation, have spurred the debate among physicians, ethicists, and patient advocates about how to help intersex children (Dreger, 1999a; Warne, Zajac & MacLean, 1998; Kessler, 1998).
One side argues that this treatment has been psychologically and physically harmful to at least some of its recipients, and that it violates the ethical principles of truth-telling, informed consent, beneficence, and authonomy (Dreger, 1999a). For instance, there is no evidence that the stress parents experience at the arrival of an intersexed child is alleviated or that attachment is facilitated by surgery, although this is the most often cited justification for the approach (Wilson and Reiner, 1998). Families and children were often discouraged from counseling “because of the almost certainly misguided assumption that talking about the reality…will undo all the ‘positive’ effect of the technological efforts aimed at covering up doubts” (Dreger, 1999b. p. 190). Surgical technique frequently sacrificed sexual sensation for cosmetic appearance and even by that measure yielded poor results (Creighton, 2001). Advocates contend that such surgeries have also not been demonstrated to determine gender identity; instead, clinicians who have encountered intersex adults whose gender identity does not match their sex-of-rearing concluded “we should be able to give an accurate prognosis regarding…gender identity on which to base gender-assignment decisions, but we are far from being able to do so at present” (Meyer-Bahlburg et al., 1996, p. 320). Patient activists argue that the patient should decide whether or not to have sexual surgeries when they are old enough to decide the consequences of this choice.
Supporters of the current paradigm of treatment argue that only a minority of patients have voiced dissatisfaction, more sophisticated surgical techniques and advances in basic science have improved results, one cannot develop a gender identity with ambiguous genitals, and virtually all parents want their children to receive surgery in infancy, before they are aware of their difference from typically sexed peers (Hendricks, 2000; Wisniewski, Migeon, Meyer-Bahlburg, Gearhart, Berkovitz, Brown et al., 2000, Meyer-Bahlburg et al., 1996; Money, Devore & Norman, 1986; Slijper et al 1999).
One of the few studies of the psychological adjustment of intersexed people was done by Money, the psychologist later responsible for the argument that intersex children should be surgically altered in infancy. Money’s study, done before the advent of modern treatment protocols, led him to conclude that his subjects were “living testimony to the stamina of human personality in the face of sexual ambiguity of no mean proportions” (in Colopinto,1999, p. 235). Inexplicably, Money would later call intersexuality, “the syndrome that stigmatizes the child as a freak – a sexual freak” (1987).
Nearly fifty years later, virtually the only long-term outcome study to evaluate psychological functioning found the picture was dramatically different for a contemporary sample treated with sex assignment, genital surgery, and psychological counseling of parents and child. Nearly forty percent of these intersexed children had developed psychopathology by age sixteen (Slijper, Drop, Molenaar, & Keizer-Schrama, 1998).
A full review of this controversy is beyond the scope of this article, but it is clear there are almost no contributions from psychoanalysis to it. In fact, one might conclude from a review of psychoanalytic literature that such anomalies and the treatment of them are nonexistent or meaningless. This seems a puzzling silence from the inheritors of the 20th century’s most elaborate theory connecting psyche to body ego. Psychoanalytic debate on gender identity argues the relative preeminence of biology, culture, and philosophy in forming theory. It is as if psychoanalysis has left these patients to the physicians who promise to reform the outlaw body, as Freud threatened to leave his defiant female homosexual patient in the hands of the genital surgeon of his time (1924). Clinicians who encounter intersexed patients have little more for guidance than their own beliefs about binary gender identity and its role in psychological health.
Review of the Analytic Literature
Freud wrote that, in contrast to the curiosity aroused by artistic representations of intersexualism, “actual hermaphroditic formation of the genitals in nature nearly always excites the greatest abhorrence” (1908, p. 216). Freud’s statement is striking because it focuses on the experience of the observer, and it is the observer’s experience — the physicians or the parents — that drives the treatment of intersex conditions. The effect of this seemingly visceral response on psychological treatment echoes through the countertransference focus on identity and the transference struggles with shame and isolation. It also reverberates through the rest of the analytic canon, which assumes that people’s bodies are either clearly male or female and that the clinician’s tasks is to reinforce this reality in patients whose gender identity diverges from the binary (Mitchell, 1997).
Only one report of an analysis with an intersexed person has been published in the past decade (Oppenheimer, 1995). One other report of such an analysis has been published in the last seventy years (Fairbairn, 1931). Other articles have described an assessment of an adolescent (Keppel & Osofsky, 1985), a long-term follow-up on a consultation (Stoller, 1985), and a brief treatment of an early adolescent (Sutton, 1998). Two recent case presentations illustrate radically different approaches to this population (Hurry, 2001; Rosario, 2001).
Fairbairn’s (1931) paper explored, but ultimately dismissed the contribution of his middle-aged intersexed patient’s biology, which “more pedestrian medical minds” might hold responsible for her symptoms (p. 220). He was not entirely immune to curiosity about the patient’s “true” sex, however; he referred her to three specialists for their opinions. Fairbain did not specify these doubts or the patient’s reactions to the referrals, although one specialist remarked that the examination “was not easy” (p. 198). Although the results were contradictory, Fairbairn concluded, “the original presumption that the patient was really female in sex must remain undisturbed: and it was never thought wise to impart to her any information which would shake her own conviction to this effect….Whatever doubts may exist…regarding her physical and physiological femininity, psychosexually at any rate she certainly conveyed the impression of being a woman; and she had a considerable attraction for heterosexual men” (p. 199).
Once convinced his patient was psychosexually female (presumably on the basis of erotic sensations he classified as clitoral rather than phallic), Fairbairn found her physical variation noteworthy only for its “psychical trauma” (which he never directly describes), and for its excluding “the possibility of a normal sexual life” (p. 220). Of her reactions to the news she did not have a vagina, he reported only that she felt relief on “being freed of the burden of womanhood”. Fairbairn expressed surprise that rather than longing for a vagina, she adapted to the reality of her anatomy by esteeming her clitoris.
Keppel & Osofsky (1985) intended to treat a 14-year-old intersexed child for gender identity disorder when the patient rejected her assigned sex and requested reassignment as male. Although the patient fled treatment before it began, this paper illustrates how the conflation of biological sex, gender identity, and object choice tangle theories of intersexuality, homosexuality, and transsexualism together in the literature. The authors attributed the patient’s belief she was a boy to a delay in surgery until the age of 22 months by parents who seemed unconvinced of the accuracy of their baby’s assignment as female, which was made on the basis of “the usual approach of rearing a sexually ambiguous child as a female” (p. 591). Despite reporting that this “active and outgoing” toddler became “shy and withdrawn” to following “the amputation of her phallus,” and lodged “vehement protests” against estrogen treatment at puberty, the authors balked at the patient’s request for surgery to masculinize her. Their hesitation was based on the surgical limitations and, because, “given the complexity of the patient’s problems and the reactions that they can evoke in treaters, the temptation may exist to rush in and solve the problems — hormonally and then surgically….however…the patient could again become disappointed and confused, experiencing increased feelings of damage, imperfection, and inadequacy” (p. 593).
Stoller (1985) reported on the development of an adolescent, presumed female until the age of 14, when an assessment triggered by virilization and the absence of menses revealed the patient had male chromosomes and anatomy. Stoller recommended to the youngster and her family that she change sexes; the family moved to a new community, the patient received surgery to masculinize his genitals, and his psychological, social, and cognitive difficulties resolved. Stoller made this recommendation because this patient had asserted a male gender identity since infancy and because, “influenced by the naturalness of ‘her’ masculinity…I acted on the clinical impression” (p. 67). Although Stoller rejected the utility of analytic theory in explaining the discordance between the child’s assigned sex at birth and gender identity, he hypothesized that his patient’s gender identity was due less to his biology and more to a failed symbiosis with the mother and identification with a strong father. Stoller’s twenty-year follow-up allowed him to report his patient’s successful adjustment to his male sex. Jack, the patient, had little memory of girlhood, but described adolescense as “the years when it was really starting to get mixed up; I didn’t know what the hell I was supposed to do” (p. 72). Jack admitted that “someone with a short pecker has his drawbacks,” chiefly the anxiety that came with revealing his genitals to someone new (p. 71). Stoller concluded, “the greatest mystery for me is the naturalness of Jack’s masculinity. That, coupled with his lack of other neurotic problems, his successful and creative life, his openness, and his honesty is unexplained. Perhaps a psychoanalysis would uncover the roots of his normality, but one does not get to analyze such people” (p. 74).
Oppenheimer’s patient, Marielle, was seventeen when she was told by a doctor that she was intersexed, although she had a surgery in early childhood (1995). Her parents had never discussed her condition with her. She initially had a fantasy of becoming a boy but had eventually accepted her assignment and hormonal treatment, although she feared that clitoral reduction would damage her sexual sensitivity. Marielle sought psychotherapy in her thirties because of depression and problems in her romantic relationship, emphasizing her dilemma of feeling enraged by people who regarded her as normal, but ashamed when they did not. Oppenheimer theorized that the patient’s lesbianism was a compromise between her feminine and masculine identifications; although she accepted the patient’s object choice, she chose to conduct the treatment from the position that “the feminine identity predominated and anything that helped to consolidate it seems to be to be positive” (p. 1195). When the patient decided to have the clitoral reduction, Oppenheimer encouraged her, but recognized that the patient was attempting to “eliminate the anxieties associated with her uncertain identity” and acknowledged that “I was — perhaps like her parents – denying her masculine part, which she was disavowing with my complicity” (p. 1195).
As does Fairbairn, Oppenheimer noted her patient’s clitoral fixation and disinterest in the vagina; like Stoller, she observed that adolescense produced an increased sense of isolation and defect, as puberty failed to be triggered by the body’s maturation.Sutton (1998) notably focused his case illustration less on the details of his teenaged patient’s body than on the countertransference experience of a treatment that necessarily focuses on “the private parts” (p. 238). His patient Lesley’s genital abnormality had been recognized but not treated in childhood, and treatment ensued when her body began to virilize at puberty. Sutton described the moment when his mental image of a girl patient collided with “the visual and auditory image of a boy” as a “physical experience–like a blow to the head, which was momentarily disorientating and shocking” (p. 240). He found himself associating to the word “scopophilia” in session, which led to an appreciation of both Lesley’s dilemma (what to do with not knowing her gender and its physical attributes) and his own. Sutton concluded the unconscious excitement provoked by unusual genitalia provoked specific countertransference challenges to the effort to think clearly about the patient, particularly uncertainty about whether one’s comments were “intrusive, aggressive…or correct professional investigations” (p. 244).
Two recent presentations have approached the treatment of intersexed patients from radically different positions. Hurry’s (2001) treatment of a prenatally androgenized adolescent girl dismissed the contribution of biology, encouraged the patient to experiment with heterosexual sex to affirm her femininity, and interpreted her sexual ambiguity as a wish. Rosario (2001) described the early stages of an analysis of a 10-year-old . The patient, assigned as female at birth because his phallus was too small, has forcefully asserted a male gender identity from earliest childhood, announcing at five “that he was a boy and wanted to be treated as a boy” (p. 6). Facing complex reconstructive surgery to restore a semblance of male genital appearance, he struggled between “a proud sense of singularity” and “the more traditional cultural image of monstrosity” (p. 7) Rosario concluded that helping his patient define himself as intersexed “may…help him resolve his anxieties about phalloplasty or decline any further surgery” (p. 8).
Each of these authors seems powerfully drawn to a single question — what is this patient’s sex? — and to explaining their answer. In each case, the analyst ultimately settles the issue in accordance with his or her subjective experience of the patient’s gender. Given the current debate over the influence of prenatal hormones in gender identity, it is striking how these gender-readings are seemingly visceral and low-tech.
While questions of gender identity are of concern to some intersexed people, what seems to be a more universal source of pain is their treatment by caregivers (Preves, 1999). Yet, the psychological impact of repeated medical interventions to the genitals in childhood is not explored in the existing literature. Preves concluded from her sample that the childhood surgery and the silence about it seemed to increase the experience of defect, isolation, and stigma it once promised to erase. She also found that once participants gained accurate information about their bodies, found others like them, and talked about their experiences, their shame was significantly reduced and identity formation began.
Neither does the existing literature address the patient who suspects but does not know that he or she is intersexed. Preves found that people often searched for years before they were able to obtain accurate information. In contrast to the conviction in the medical literature about the dire consequences of such a discovery, first-person accounts and case reports suggest that psychological functioning is often enhanced when such histories are revealed (Colapinto, 2000; Natarjan, 1996; Stoller, 1985). One intersex writer put it, “secrecy as a method of handling troubling information is primitive, degrading, and often ineffective. Even when a secret is kept, its existence carries an aura of unease that most people can sense….Secrets crippled my life.” (Kemp, 1996, p. 1829). The following case presentation is an effort to contribute to our understanding of both of these topics: the psychological impact of invasive urogenital treatment in childhood, and the fear that this treatment is related to an intersex condition.
The reasons for Kristin’s lifelong depression were particularly unclear when we began working together in her twenties; her earliest memory was of an incident at age twelve when she argued with her mother after a doctor’s appointment. She had come to therapy because of her worry that “something might be hidden back there,” but for a long time could not say more about what it might be. A routine question about childhood illnesses seemed to provoke a momentary spaciness; when I inquired, she said she had no memories, but was troubled by images she did not want to elaborate.
A few weeks later, Kristen mentioned she had a hormonal imbalance that required medication. Asked how the diagnosis had been made, Kristen replied she began to grow facial hair at age 12. I wondered aloud if her first memory of the doctor’s visit was related to this problem, Kristen confirmed that it was, then seemed baffled she hadn’t connected the events. Curious for the details, Kristin called her mother, who accused Kristin simultaneously of making something out of nothing and bringing up bad memories. After extended diplomacy on K’s part, she was told she’d had bladder and bowel problems that required surgical repair and treatment throughout latency; Kristin noted that these explanations differed from what she had been told on another occasion.
Kristin’s resentment grew as she recollected her parents’ lack of emotional support for her medical ordeal. She remembered being told as a little girl that she was going to an amusement park only to arrive first at the hospital for a painful procedure, She recalled her parents’ irritation when she was too drained to enjoy the park trip that followed. This was difficult enough material, but as we explored it in the next year, Kristin seemed as troubled by, and less able to voice, an idea that these memories might say something about her body. At times she shared her mother’s opinion that she was making something out of nothing and suggested that I had ulterior motives.
At this point, early in a weekly treatment, my conscious countertransference was a sort of impotent confusion. I felt exquisitely needled, even ashamed by her conviction I was on to something when I wasn’t sure what any of this meant. Looking back, I see that she was right: I wanted to know what had happened because it was hard to connect to her without knowing more about her life history, particularly when Kristin spent many of these early sessions helplessly and frustratingly silent. It felt like we both settled for working on day-to-day problems because I couldn’t find a way to explore her alienation and fear without somehow leaving her feeling more alienated and fearful than before.
After two years, we agreed to begin an analysis and Kristin began to discuss her body, more specifically her dissatisfaction with her weight. Kristin disclosed she had been binge eating, a longstanding problem. She sounded a desperate refrain: “My body is disgusting. I feel like a freak.” It took weeks for it to occur to me that I was assuming Kristin was talking only about her weight. I asked one day whether there was anything else about her body that made her feel like a freak. She replied that if she didn’t take her medication, she stopped menstruating and grew facial hair.
“What does that mean for you?” I asked.
After another long silence, she said in a small voice, “I don’t think I’m a woman completely.”
“Because of the medication?” I asked.
“Partly,” she said. “But my genitals don’t look like other women’s genitals. I’ve never seen anyone with a body like mine.” She described trips to the medical library in the hopes of finding an answer.
Coen (1998) describes the oscillation among three perspectives in patients who are attempting to bear the unbearable: at times being able to discuss the conflict, at times being unable to, and at times refusing to do so. As Kristin began to relate her fears about her body, this oscillation dizzied me. She recollected first knowing something was different about her when groups of doctors, nurses and medical students would gather to look at her in the hospital. The procedures were painful and humiliating; she was given neither advance notice or explanation. As a little girl, she believed that the doctors had damaged her. She described a feeling that “something was being ripped out of me, some piece of me that I couldn’t get back.” She felt the damage was so terrible that no one would even speak of it to her. She wished there was a name for what had happened to her. Then, after trying to make meaning out of her fragmented memories, she would retreat to her mother’s opinion that she was making a big deal out of nothing.
I suggested that the reasons for her treatment might never be known and were not important, but I also began my own trips to the medical library. My conscious reason for researching urogenital procedures on small children was that I needed to know what Kristin experienced. But I was also curious, and anxious about being curious, and the reading was my compromise formation. The literature confirmed that many of these patients experienced their treatment as extremely traumatic and the source of longstanding psychological damage (Shopper, 1995; Money & Lamacz, 1987). Some authors attributed this to displaced rage over having a defective body (Money and Lamacz) while others (Shopper) saw these experiences of public humiliation as the source of psychological pain in themselves. Shopper noted that the traumatic impact was “greater the younger the child, the less the external support, the fewer the ego capablities, and the less the preparation” (1995, p. 191). An adult patient of Shopper’s struggled between the wish to express emotion and an effort to preserve the privacy her invasive treatments had destroyed. Rosenblitt (1991) found that genital procedures in childhood influenced the patient’s fantasies of injury, of sexual differences, and oedipal configurations. This literature overlapped with another concerning the treatment of children born with ambiguous genitalia, and I noticed the vague explanations given to these children resembled those given to Kristin.
But I said nothing to my patient about what I was reading. I could find no consensus about what I should say — rather, I encountered two adamantly opposed camps among my colleagues — so I elected to wait for her to lead the way. For a while, this seemed like the right decision. We worked on her sense of helplessness in the face of medical and parental authority. She began to talk more openly about her sense that being a woman depended on the medication she took. She eventually began to feel as if she had a self in spite of her uncertainty about her body, a self who deserved to be cared for. She overcame her fears of being rejected enough to begin to make friends. She reported less bingeing and her weight stabilized. I occasionally referred to her worries about her body, but she told me the subject left her frightened about what I was imagining when I asked
Once, she wondered what it would be like to stop taking her medication. “There’s a part of me that wants to see what I would look like if I just let my body take charge of itself.”
“Or if you took charge of it,” I said. “You feel your body was taken away from you by the doctors.”
“Well, I know it isn’t mine. I don’t even know what it’s like.”
Kristin reported a dream soon after. “I am at a party in a park, with lots of people and food. We’re all relaxed. Then suddenly people are running for the woods. I turn around and see someone holding a little child, and someone else holding the arm separately. It had been eaten off. I am horrified; I don’t know if anyone can survive this.” She recognized the dream as recreating a particular moment that happened repeatedly in her life: that of being terribly shocked when she let her guard down. She described the doctor’s appointment she had originally designated her first memory, when she was subjected to a pelvic examination by a male doctor who said only, “I need to see your scars.” Later he talked about her having “male hormones”, and it was at this moment, as a shy twelve-year-old alone on an examination table, that Kristin began to replace her belief that doctors had damaged her with a worry that there had been something wrong with her to begin with. She told me she was frightened by how much she had told me about her fears of sexual ambiguity.
“Are you afraid that I think your surgery was to alter your genitals?” I asked impulsively.
“Don’t say that,” she said immediately, “that’s not me.” We sat quietly until she spoke again. “I think that is what happened. I looked at the doctor’s notes for years to see if I could tell what they meant. If you tell me I can believe myself, then what am I? If you believe this is what happened, then it really happened.”
“I don’t know what happened to your genitals or why,” I replied. “But whatever happened was a long time ago and you are yourself. You will always be yourself, whatever you discover about your past and whatever has happened to your body. “ I realized as I spoke that a part of me had been terrified about this moment, of Kristin asking what I thought. I was relieved I didn’t know what had happened. But when Kristin voiced her fear that her genitals had been the focus of her medical treatment, I felt sure she was right and sure I needed to hide this opinion, too. I was afraid the excitement of correctly guessing the secret would keep me from empathizing with her.
I began looking for people to learn from. I contacted the Intersex Society of North America and joined a listserv with intersexed members. I began to fantasize about introducing Kristin to a community of people who could combat her sense of isolation. I put my outrage and knowledge to work teaching medical personnel about the controversy over genital surgeries on children. I also began to read analytic literature on sex and gender more critically. Nearly all of this literature assumed that people are either clearly male or female and so didn’t address Kristin’s experience of her body as different. I realized that psychoanalysis was claiming an authority on the topic of sexual development that I no longer found credible (Mitchell, 1997). Ultimately, I had to acknowledge to myself that we don’t know and probably never will know how the body, the culture, and the imagination impose a gender on an individual.
Yet I was sharing none of this with Kristin. As I immersed myself in reading, I missed her shift away from anxiety that she wasn’t female and toward a feeling that, as she put it, “I didn’t have a self as a child. It was like half of me is missing. I don’t know what they ripped out of me.” I think I missed this because I felt her history was so traumatic that there was nothing I could do to help. Working through her parents’ idealization of physical appearance helped her separate her sense of feminine identity from her parents’ more external and superficial standards. Yet I imagined she was still talking about just her body.
In our third year, I asked her permission to present her case at a talk I was giving in another state. I described it as an opportunity to help other clinicians who might encounter people with similar problems and she agreed in the same spirit of detached benevolence. I ended that presentation with the following dream, prompted by Kristin’s puppy’s first heat and her panic that she would have to get her pet spayed. “The doctor takes me into the operating room. My dog is asleep on the table. She is cut open. He points at her insides to show me the dog isn’t male or female. He says, “we don’t know the sex of this dog.”
“What did you feel at that moment in the dream?” I asked.
“Glad she was a dog and glad I was her mother. Because she would never have know she was different, and because it didn’t matter to me.” When she spoke again, it was about herself. “I don’t know if I ever will find out what happened to me. I’m not even sure I’ll ever want to know. Maybe I’m not ready to know. Everything changes then.”
“Is there are a piece of knowing that matters to you now?” I asked.
“I’d like to know why my mother and father didn’t help me, why they would leave me crying in my room and not ask what was wrong. They’ll never see if from my point of view.”
“And how is it for you to see it from your point of view, without their help? “
“I see it and I don’t. I don’t want to see it all the time. I have to stop short of that. Because then I realize that it could have been different, that if they had protected me, I wouldn’t be feeling like this now, afraid to have anyone come close to me. So I come just that close, and then I don’t know what to do next.”
It has taken another year for me to understand how Kristin’s dream and associations were about our relationship, specifically about a doctor who is preoccupied with the mystery of a patient’s body, distracted from the patient but eager to discuss her with an observer. She began to tell me how troubled she was that my description of her centered on her worries about gender. “It’s not that you had it wrong,” she said, “you had it right in some ways, but the words are so scary. I know now I’m a woman in the right body, but I’m trying to put these pieces together, and people who hear you will think I’m a freak.”
I had to ask myself whether my compromise of becoming a critic of intersex treatment had actually protected Kristin. I pondered a line by Boesky: “If the analyst does not get emotionally involved sooner or later in a manner he had not intended, the analysis will not proceed to a successful conclusion” (1990, p. 573).
Renik’s (1993) metaphor of the analyst as a skier or surfer resounded – someone who allows herself to be acted upon by powerful forces, “knowing that they are to be managed and harnessed, rather than completely controlled” (in Mitchell & Aron, 1999, p. 417). I contemplated that word “powerful”. What was the power these forces had had on me? When would I find a way to harness them? All my activity had been to conceal a countertransference about which I felt great shame: ignorance, shock, curiosity, excitement, self-congratulation. What had my decision to hide these reactions left Kristin feeling?
Soon after, Kristin reported a health problem that would require a doctor’s visit. As was the case for any medical encounter, the prospect was so troubling she couldn’t find the words to describe it to me. She wished I could understand what she was up against without her having to explain, but she also felt guilty for wanting to traumatize me by being explicit about what she experienced.
“I think there are times we both wish you didn’t have this body,” I said. “This body gets in the way between us, and it’s done that to you all your life with one relationship after another. It haunts you with these images, it makes you feel bad about yourself. If you don’t tell people about it, you feel like no one really knows you, and if you do, you have to worry about what they’re thinking.”
She nodded, saying this was true. I went on. “I have to admit that when you have these memories, I wish you could describe them. I am curious about your body, and I find myself worried my curiosity will hurt you if I admit to it. But how could I not be curious about this part of you? I’m curious about everything else, and this body is so central to the story you’re telling.”
“I know you’re curious,” she said.
“I bet you do. And you’ve been stuck trying to figure out what happened all by yourself, and that includes trying to figure out which of your guesses are accurate and which aren’t.”
“I think it’s hard to even find the right words,” Kristin said. “Sometimes it’s okay if you say “intersex” or “ambiguous genitals” and sometimes I can’t stand it.”
“I noticed that,” I said. “Do you notice how sometimes we both end up saying something about ‘that’?”
“This thing, ‘that’, is so powerful,” she said.
“And there are no right words to put to it.”
“And when you put words to it, it scares the crap out of me.”
Since then, we’ve talked about how our silence has also been a mutual effort to sustain the pretense that harm hasn’t already been done. We remain in this space, which finally allows Kristin to express her anger at me for wanting to know the cause of her condition rather than focusing on the trauma of its treatment. She insists that I consider the possibility that no secrets have been kept from her, because, she says, the secrets no longer matter to her. I continue to work to let go of my need for her to acknowledge the conflict between this wish and others she has voiced.
When I began to suspect Kristin might be intersexed, a colleague cautioned me, “Don’t let your imagination run away with you. What happened may be a very minor anomaly in anatomy.” Thinking about his advice, I found myself struggling with my own sense of shame about an ambiguity: why was I drawing a connection between Kristin and intersexed people when I didn’t know if the connection was real?
I think my colleague had a very good point; yet minor anomalies in anatomy are often precisely the impetus for genital surgery on infants. The reasons given for such surgeries are the apparently insurmountable social difficulties of being a girl with a large clitoris, or a boy who cannot urinate from a standing position. One wonders if the reason has less to do with the rare occasions on which the genitals are shown publicly and more to do with how such minor variations do something to the observer’s imagination, something potentially analyzable.
If Kristin reveals her history to other people, her relationships with them become mediated by their preoccupation with her anatomy. If she does not, she is left with a sense of isolation and shame. These interpersonal dilemmas connect her to what intersex people experience. What may be most difficult about intersexed life is not the appearance of the body, but the means by which ‘optimal’ sex is imposed upon it. Actions regarded as repair by doctors and parents are experienced as damage by the recipient. The mistrust and shame created by parental and medical deception is a further source of trauma. The belief there are only two sexes with a a clear physical demarcation between them justifies the hopelessness some intersexed people feel about consulting psychotherapists for help.
That some of our bodies do not neatly fit into the categories of male and female seem to many clinicians and theorists either a psychotic delusion or some sort of naive utopian ideal. But intersexed people are not figments of their imaginations. They have been injured by our treating them as if they were figments of ours. A striking contradiction in our approach to gender emerges when one reads theory on adult transsexuals side by side with the literature on intersexed children. We seem to hesitate to endorse surgery for adults who wish to alter their genitals because of our concern that this is a permanent, imperfect solution to an emotionally complex dilemma. Yet we fail to protest subjecting babies born with ambiguous genitalia to precisely these same surgeries, performed early in their lives, and with such secrecy and lack of preparation that the medical trauma is magnified.
Are physicians correct in their belief that the parents’ anxiety can only be resolved by these means? What sort of attachment is fostered when a child’s body is altered to win acceptance? Nelki and Sutton point out that “a lack of certainty may cause considerable anxiety and confusion, but the wish to provide an immediate soluton…,ay be less helpful…than the ability of professionals to assist parents in tolerating these feelings” (1998, p. 103) The argument that it is impossible to have a social, sexual, or emotional life without such alterations is insupportable in the face of Money’s original research findings. It is also reminiscent of the arguments made thirty years ago that it was impossible for gay and lesbian people to be happy in a heterosexual world. This position promotes a more strictly limited conception of male and female than the one we’ve come to associated with health in typically sexed people. For those with the right equipment, we encourage the appreciation of male and female aspects of the self and the freedom to play with both, to establish one’s idiosyncratic gender as a powerful source of psychological wholeness (Winnicott, 1966).
Kristin’s worry about her gender appears to have been eased by the experience of voicing it. What remains more deeply troubling to her is the assault on her bodily integrity by repeated medical procedures and the assault on her sense of reality by the silence surrounding them. From a psychodynamic perspective, the current paradigm seems designed to concretely resolve a problem – not the problem of the ambiguous body, but the problem of our “universal abhorrence,” to return to Freud’s apt phrase. Yet this response also creates a tradition of misattunement, one clearly reenacted in this analysis. Kristin’s caretakers focused on altering her body and concealing the reasons, as if no harm has been done if nothing is revealed. While the caretakers disavow, Kristin has lost something and no one will help her grieve that loss. Winnicott described this failure, cautioning that although parental attention is drawn to the repair of the damaged child, what the child needs more fundamentally is the feeling of being loved and accepted in the as-born body (1972). I do not know what Kristin’s body looked like at birth or whether the surgeries she has had were to alter her genitals, but my focus on knowing has blocked my truly appreciating how alone she is in a world where, as she puts it, “no one has a body like mine.” Being with her has made me understand how what is hidden between the legs of a child has evoked the most extravagant reactions in a world unable to look away from the body, all wild spray from the transformation of the child into a symbol – of disorder, monster, outlaw, even freedom fighter. How easy it is to circle endlessly within these fantasies, leaving the child behind.
Psychoanalysis’s unexamined acceptance of this treatment contradicts our shift away from unsupported positions of authority. As Mitchell wrote, “the most interesting and productive moments…of analytic work are often precisely those spent outside that familiar, reassuring, professional self — times when confusion, dread, excitement, exasperation, longing, or passion is the dominant affect. This does not involve a cultivation of not knowing or noncontrol, but an effort to free oneself from compulsive knowing and mandatory control” (1997, p. 193).
Further psychoanalytic exploration of intersex experience could give insight into the complicated dynamics underpinning the current treatment paradigm. The debate on the consequences of a shift to a more patient-based approach (which recommends postponement of all non-emergent surgery until the child is old enough to make an informed decision) will be enriched by clinicians sharing their experiences in working with this population. Such reports will expand the definition of outcome measures to include psychological functioning, family health, and erotic sensation, rather than the merely cosmetic and behaviorally based measures of gender currently employed. Analytic exploration of other aspects of intersex experience will also be helpful, as well, including the phenomena of robust self-esteem in untreated intersex adults, the interpersonal dynamics leading to the clinician’s automatic assignment of gender, and the extension of techniques of treating sexual trauma and birth anomalies to this population. Such efforts would extend the reach of psychoanalytic thought to a population that surely needs its resistance to concrete, biological solutions to complex questions. Finally, analysis of gender identity in individuals who identity as intersex would add a valuable dimension to our understanding of this difficult, evolving concept.
Blackless, M., Caruvastra, A., Derryck, A., Fausto-Sterling, A., Lauzanne, K., & Lee, E. (2000). How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology, 12(2): 151-166.
Boesky, D. (1990). The psychoanalytic process and its components. Psychoanalytic Quarterly, 59: 550-584.
Coen, S.J. (1998). How to help patients (and analysts) bear the unbearable. Journal of the American Psychoanalytic Association, 45(4): 1183-1207.
Colapinto, J., 2000. As Nature Made Him: The Boy Who Was Raised As A Girl. New York: Harper Collins.
Creighton, S. (2001). Surgery for intersex. Journal of the Royal Society of Medicine, 94: 218-220.
Diamond, M. & Sigmundson, H.K. (1997). Sex reassignment at birth: long-term review and clinical implications. Archives of Pediatric and Adolescent Medicine, 151: 298-304.
Dreger, A.D. (1999a). Intersex in the Age of Ethics. Hagerstown, MD: University Publishing Group.
Dreger, A.D. (1999b). Hermaphrodites and the Medical Invention of Sex. Cambridge: Harvard University Press.
Dreger, A.D. (1998). Ambiguous sex – or ambiguous medicine – in the treatment of intersexuality. Hastings Center Report.
Fairbairn, W.D. (1931). Features in the analysis of a patient with a physical genital abnormality. In Fairbairn, W.R.D., Psychoanalytic Studies of the Personality (pp. 197-222). London: Routledge, 1992.
Freud, S. (1908). On the sexual theories of children. Standard Edition, 9
Freud, S. (1924). Psychogenesis in a case of homosexuality in a woman. Standard Edition, 7:7- 122. London, Hogarth Press, 1953.
Hendricks, M. (2000, September). Into the hands of babes. Johns Hopkins Magazine. Retrieved September 15, 2001, from http://www.jhu.edu/~jhumag/0900web/babes.html
Hurry, A. (2001, May). A plea for a measure of uncertainty. Anna Freud Lecture presented at The New York Freudian Society, New York City, NY.
Kemp, B.D. (1996). Sex, lies and androgen insensitivity syndrome, Canadian Medical Association Journal. 154: 1827-1828.
Keppel, W.H. & Osofsky, H.J. (1985). A patient with ambiguous genitalia and gender confusion. Bulletin of the Menninger Clinic, 49(6): 584-595.
Kessler, S.J. (1998). Lessons from the Intersexed. New Brunswick, NJ: Rutgers University Press.
Meyer-Bahlburg, H., Gruen, R., New, M., Bell, J., Morishima, A., Shimshi, M. et al. (1996). Gender change from female to male in classical congenital adrenal hyperplasia. Hormones and Behavior, 30: 319-332.
Mitchell, S. (1997). Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: The Analytic Press.
Money, J., Devore, H., & Norman, B. (1986). Gender identity and gender transposition: longitudinal outcome study of 32 male hermaphrodites assigned as girls. Journal of Sex & Marital Therapy, 12 (3), 165-181.
Money, J. & Lamacz, M. (1987). Genital examination and exposure experienced as nosocomial sexual abuse in childhood. Journal of Nervous and Mental Disease, 175 (12): 713-721.
Natarajan, A. (1996). Medical ethics and truthtelling in the case of AIS. Canadian Medical Association Journal. 154: 568-570.
Nelki, J. and Sutton, A. (1998). Emotional aspects of gynaecological problems at birth. In Garden, A.S. Paediatric & Adolescent Gynaecology. London: Arnold.
Nussbaum, E. (1999, May/June). The sex that dare not speak its name. Lingua Franca, pp. 42- 50.
Oppenheimer, A. (1995). Considerations on anatomical and psychic reality in relation to an intersexual patient. International Journal of Psychoanalysis, 76, 1191-1204.
Preves, S. (1999). For the sake of the children. In Dreger, A.D. (Ed). Intersex in the Age of Ethics (pp. 51-68). Hagerstown, MD: University Publishing Group.
Reiner, W.G. (1996). Case study: Sex reassignment in a teenage girl. Journal of the American Academy of Child and Adolescent Psychiatry, 35:6, 799-803.
Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of the analyst’s irreducible subjectivity. In Mitchell, S. and Aron, L (Eds.), 1999: Relational Psychoanalysis: The Emergence of a Tradition (pp. 407-424). Hillsdale, NJ: The Analytic Press.
Rosenblitt, D. (1991). Some conjectures about the role of reconstruction in child analysis. Child Analysis, 2: 16-33.
Rosario, V. (2001, April). The boy with labia: intersexes and iatrogenic transsexualism. Talk presented at Yale University, New Haven, CT.
Slijper, F.M.E., Drop, S.l.S., Molenaar, J.C. & Keizer-Schrama, S.M. (1998). Long-term psychological evaluation of intersex children. Archives of Sexual Behavior, 27: 125-144.
Slijper, F., Drop, S., Molenaar, J., Keizer-Schrama, S. (2000). Response to Milton Diamond and Cheryl Chase. Archives of Sexual Behavior, 29 (1)” 119-121.
Shopper, M. (1995). Medical procedures as a source of trauma. Bulletin of the Menninger Clinic, 59(2): 191-204.
Stoller, R. (1985). How biology can contribute to gender identity. In Stoller, R., Presentations of Gender (pp.65-76). New Haven: Yale University Press.
Sutton, A. (1998). “Lesley”: the struggle of a teenager with an intersex disorder to find an identity–its impact on the “I’ of the beholder. In Di Ceglie, D. & Freeman, D. (eds). A Stranger In My Own Body: Atypical Gender Identity Development and Mental Health (pp. 237-248). London: Karnac Books.
Warne, G.L., Zajac, J.D., MacLean, H.E. (1998). Androgen insensitivity syndrome in the era of molecular genetics and the Internet: a point of view. Journal of Pediatric Endocrinology and Metabolism, 11(1): 3-9.
Winnicott, D.W. (1966). The split-off male and female elements to be found in men and women. In Winnicott, C., Shepherd, D., and Davis, M, (Eds.), Psycho-Analytic Explorations (pp. 168-192). London: Karnac Books, 1989.
Winnicott, D.W. (1972). The basis for self in body. International Journal of Child Psychotherapy, 1: 7-16.
Wisniewski, A., Migeon, C., Meyer-Bahlburg, H., Gearhart, J., Berkovitz, G., Brown, T., and Money, J. (2000). Complete androgen insensitivity syndrome: long-term medical, surgical, and psychosexual outcome. The Journal of Clinical Endocrinology and Metabolism, 85(8): 2664-2669.
Psychoanalytic Psychology, Vol. 19, No. 3, 455-474, Copyright 2002 by the Educational Publishing Foundation
American Psychological Assn. Journal of Psychoanalytic Psychology Reprinted with permission of the author.