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       "‘We are all born naked’ – is the rest drag? Some thoughts on gender identity development and psychoanalysis"



 By Beate Schumacher  


The author is a Fellow of the Institute of Psychoanalysis (London), qualified in the analysis adults, adolescents and children. Until its closure, she worked on the Families Unit of the Cassel Hospital and, in addition to her private practice, continues to hold positions in the NHS, with a Tier 2 outpatient psychotherapy team and in a forensic service. She has taught both in the UK and in Germany, and is a senior lecturer on the MSc in Psychodynamic Approaches to Mental Health run jointly by Bucks New University and West London Mental Health Trust. Having contributed to its work for many years, she currently chairs the European Psychoanalytic Federation Forum for the Psychoanalysis of Children.









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"Enactment in Psychoanalysis"

Edited by Giuseppe Leo & Giuseppe Riefolo

Writings by:   E. Ginot  J.R. Greenberg  J. Kraus  J.D. Safran

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Collection: Borders of Psychoanalysis

Year: 2019

Pages: 326

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"Infant Research and Psychoanalysis"

Edited by Giuseppe Leo

Writings by:   B. Beebe  K. Lyons-Ruth  J. P. Nahum  E. Solheim  C. Trevarthen   E. Z. Tronick     L. Vulliez-Coady

Publisher: Frenis Zero

Collection: Borders of Psychoanalysis

Year: 2018

Pages: 273

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"Fundamentalism and Psychoanalysis"

Edited by Giuseppe Leo

Prefaced by: Vamik D. Volkan

Writings by:   L. Auestad   W. Bohleber     S. Varvin  L. West

Publisher: Frenis Zero

Collection: Mediterranean Id-entities

Year: 2017

Pages: 214

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"Psicoanalisi, luoghi della resilienza ed immigrazione"

Edited by/a cura di:                    Giuseppe Leo                                       Writings by/scritti di:                           S. Araùjo Cabral,  L. Curone,               M. Francesconi,           L. Frattini,           S. Impagliazzo, D. Centenaro Levandowski, G. Magnani, M. Manetti,  C. Marangio,       G. A. Marra e Rosa,   M. Martelli, M. R. Moro,                        R. K. Papadopoulos,  A. Pellicciari,        G. Rigon,            D. Scotto di Fasano,   E. Zini, A. Zunino           

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"Psicoanalisi in Terra Santa"

Edited by/a cura di: Ambra Cusin & Giuseppe Leo                              Prefaced by/prefazione di:               Anna Sabatini Scalmati                Writings by/scritti di:                          H. Abramovitch  A. Cusin  M. Dwairy A. Lotem  M. Mansur M. P. Salatiello       Afterword by/ Postfazione di:            Ch. U. Schminck-Gustavus                 Notes by/ Note di: Nader Akkad

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"Essere bambini a Gaza. Il trauma infinito" 

Authored by/autore: Maria Patrizia Salatiello                                     

 Editore/Publisher: Edizioni Frenis Zero

Collection/Collana: Mediterranean Id-entities

Anno/Year: 2016

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Psychoanalysis, Collective Traumas and Memory Places (English Edition)

Edited by/a cura di: Giuseppe Leo Prefaced by/prefazione di:               R.D.Hinshelwood                                      Writings by/scritti di: J. Altounian       W. Bohleber  J. Deutsch                        H. Halberstadt-Freud  Y. Gampel           N. Janigro   R.K. Papadopoulos            M. Ritter  S. Varvin  H.-J. Wirth

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"L'uomo dietro al lettino" di Gabriele Cassullo

 Prefaced by/prefazione di: Jeremy Holmes                                                         Editore/Publisher: Edizioni Frenis Zero

Collection/Collana: Biografie dell'Inconscio

Anno/Year: 2015

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"Neuroscience and Psychoanalysis" (English Edition)

Edited by/a cura di: Giuseppe Leo Prefaced by/prefazione di: Georg Northoff                                            Writings by/scritti di: D. Mann               A. N. Schore R. Stickgold                   B.A. Van Der Kolk  G. Vaslamatzis  M.P. Walker                                                 Editore/Publisher: Edizioni Frenis Zero

Collection/Collana: Psicoanalisi e neuroscienze

Anno/Year: 2014

Pagine/Pages: 300


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Vera Schmidt, "Scritti su psicoanalisi infantile ed educazione"

Edited by/a cura di: Giuseppe Leo Prefaced by/prefazione di: Alberto Angelini                                             Introduced by/introduzione di: Vlasta Polojaz                                                   Afterword by/post-fazione di: Rita Corsa

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Collana: Biografie dell'Inconscio

Anno/Year: 2014

Pagine/Pages: 248


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Resnik, S. et al.  (a cura di Monica Ferri), "L'ascolto dei sensi e dei luoghi nella relazione terapeutica" 

Writings by:A. Ambrosini, A. Bimbi,  M. Ferri,               G. Gabbriellini,  A. Luperini, S. Resnik,                      S. Rodighiero,  R. Tancredi,  A. Taquini Resnik,       G. Trippi

Editore/Publisher: Edizioni Frenis Zero

Collana: Confini della Psicoanalisi

Anno/Year: 2013 

Pagine/Pages: 156


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Silvio G. Cusin, "Sessualità e conoscenza" 

A cura di/Edited by:  A. Cusin & G. Leo

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Collana/Collection: Biografie dell'Inconscio

Anno/Year: 2013 

Pagine/Pages: 476

ISBN:  978-88-97479-03-1

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AA.VV., "Psicoanalisi e luoghi della riabilitazione", a cura di G. Leo e G. Riefolo (Editors)


A cura di/Edited by:  G. Leo & G. Riefolo

Editore/Publisher: Edizioni Frenis Zero

Collana/Collection: Id-entità mediterranee

Anno/Year: 2013 

Pagine/Pages: 426

ISBN: 978-88-903710-9-7

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AA.VV., "Scrittura e memoria", a cura di R. Bolletti (Editor) 

Writings by: J. Altounian, S. Amati Sas, A. Arslan, R. Bolletti, P. De Silvestris, M. Morello, A. Sabatini Scalmati.

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Collana: Cordoglio e pregiudizio

Anno/Year: 2012 

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ISBN: 978-88-903710-7-3

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AA.VV., "Lo spazio  velato.   Femminile e discorso psicoanalitico"                             a cura di G. Leo e L. Montani (Editors)

Writings by: A. Cusin, J. Kristeva, A. Loncan, S. Marino, B. Massimilla, L. Montani, A. Nunziante Cesaro, S. Parrello, M. Sommantico, G. Stanziano, L. Tarantini, A. Zurolo.

Editore/Publisher: Edizioni Frenis Zero

Collana: Confini della psicoanalisi

Anno/Year: 2012 

Pagine/Pages: 382

ISBN: 978-88-903710-6-6

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AA.VV., Psychoanalysis and its Borders, a cura di G. Leo (Editor)

Writings by: J. Altounian, P. Fonagy, G.O. Gabbard, J.S. Grotstein, R.D. Hinshelwood, J.P. Jimenez, O.F. Kernberg,  S. Resnik.

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Anno/Year: 2012 

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ISBN: 978-88-974790-2-4

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AA.VV., "Psicoanalisi e luoghi della negazione", a cura di A. Cusin e G. Leo
Psicoanalisi e luoghi della negazione

Writings by:J. Altounian, S. Amati Sas, M.  e M. Avakian, W.  A. Cusin,  N. Janigro, G. Leo, B. E. Litowitz, S. Resnik, A. Sabatini  Scalmati,  G.  Schneider,  M. Šebek, F. Sironi, L. Tarantini.

Editore/Publisher: Edizioni Frenis Zero

Collana/Collection: Id-entità mediterranee

Anno/Year: 2011 

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ISBN: 978-88-903710-4-2

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"The Voyage Out" by Virginia Woolf 

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ISBN: 978-88-97479-01-7

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Pages: 672

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"Psicologia dell'antisemitismo" di Imre Hermann

Author:Imre Hermann

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ISBN: 978-88-903710-3-5

Anno/Year: 2011

Pages: 158

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"Id-entità mediterranee. Psicoanalisi e luoghi della memoria" a cura di Giuseppe Leo (editor)

Writings by: J. Altounian, S. Amati Sas, M. Avakian, W. Bohleber, M. Breccia, A. Coen, A. Cusin, G. Dana, J. Deutsch, S. Fizzarotti Selvaggi, Y. Gampel, H. Halberstadt-Freud, N. Janigro, R. Kaës, G. Leo, M. Maisetti, F. Mazzei, M. Ritter, C. Trono, S. Varvin e H.-J. Wirth

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ISBN: 978-88-903710-2-8

Anno/Year: 2010

Pages: 520

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"Vite soffiate. I vinti della psicoanalisi" di Giuseppe Leo 

Editore/Publisher: Edizioni Frenis Zero

Edizione: 2a

ISBN: 978-88-903710-5-9

Anno/Year: 2011

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"La Psicoanalisi e i suoi confini" edited by Giuseppe Leo

Writings by: J. Altounian, P. Fonagy, G.O. Gabbard, J.S. Grotstein, R.D. Hinshelwood, J.P. Jiménez, O.F. Kernberg, S. Resnik

Editore/Publisher: Astrolabio Ubaldini

ISBN: 978-88-340155-7-5

Anno/Year: 2009

Pages: 224

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"La Psicoanalisi. Intrecci Paesaggi Confini" 

Edited by S. Fizzarotti Selvaggi, G.Leo.

Writings by: Salomon Resnik, Mauro Mancia, Andreas Giannakoulas, Mario Rossi Monti, Santa Fizzarotti Selvaggi, Giuseppe Leo.

Publisher: Schena Editore

ISBN 88-8229-567-2

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Tasked with writing this paper, I have spent much of the year reading up on the development of gender identity, hoping to provide you with an outline of normal development and the departures from it. The more I read, the more impossible this endeavour seemed to become. There is no straight developmental line towards ‘normal’ gender identity, let alone consensus in the psychoanalytic world or any other as to what constitutes normal gender identity or normal development. What ‘gender’ denotes is not clear – a cultural construct, the psychic representation of masculinity and femininity, “all the members of one sex” (Collins English Dictionary), or the “state of being male, female or neuter” (ibid.)? Even where a differentiation is assumed, for example between gender as a psychological phenomenon distinct from and relatively independent of biological, or anatomical, or natal sex, there is often slippage between concepts. The choice of ‘biological’, or ‘anatomical’, or ‘natal’ sex, ostensibly to describe the same material facts, can itself contain a subtle declaration of allegiance to one view or another – and there are very different views about how material the facts referred to are or need to be. 


I have miserably failed to meet my brief. Though sharing with you some of the difficulties I encountered, and some of the questions I was left with will, I hope, help to set a frame for this weekend’s discussions. 


Sex and gender 

The very first problem I came up against is the meaning of ‘gender’. In my mother tongue, we do not have separate terms for biological sex and gender, and the word we use for both – Geschlecht – has other meanings in addition, which translate back as race [Gattung], kinship group [Sippe], lineage [Abstammung] and generation [Generation] (Collins German Dictionary). I imagine if we went around the room, more of these linguistic peculiarities would be found. Thus, from the beginning, sex and/or gender are imbued with culture, with history and with significations that are not the same depending on where you are born. Gender and sex may be more or less distinct concepts depending on the language you learn. 

Though wherever on earth your mother might have given birth to you, whatever might have become your fatherland or your mother country, your body would have been what it was. It comes in two basic models and a variety of shades, plus the exceptions – very few – that prove the rule. And wherever its origins, this body would have been on course for a developmental arc, the four ages of man – or Mensch, as we would say in my language, indicating neither sex nor gender – that is the fate of everyone; unless you die first. We might add puberty and the menopause to what the body will do by itself, if left to its own devices, irrespective of how anyone speaks about it. 

Gender and sex may be more or less distinct concepts depending on your native tongue, which may give you more or less extensive, and more or less specialist vocabularies with which to speak about either, but, unless you are one of the few exceptions, there would have been no  ‘more or less’ about your biological sex. The two more or less distinct concepts, sex and gender, describe categories with very different properties: a binary non-choice in the first case – I shall give up mentioning the exceptions for brevity’s sake – and endless possibilities, as we shall see, in the other. The relationship between the two cannot but be a challenge. 

RuPaul breaks into song with his/her attempt to rise to it: “We’re all born naked and the rest is drag”1 . For Robert Stoller, who famously coined the phrase ‘core gender identity’ in the 1960s, the rest was, a little more encompassing, culture. Drawing a distinction between ‘sex’ as the biological factor and ‘gender’ as the social contribution to who we are, or become, he came to see gender as largely culturally determined; biological forces may augment or interfere with the post-natal learning of it, much of it completed by the age of two. Though, as he would have been the first to admit, the research which informed his view, at UCLA’s Gender Identity Clinic, was of course itself bound by a very particular, mostly white, mostly middle-class cultural context (Stoller, 1968 [1984]). Stoller’s view, that gender is pretty much independent of the body, was welcomed by many, not least because it mitigates against an ‘essentialist’ pathologizing of non-binary choices and the violent prejudice it can give rise to (see for example: Marsh, 2017). 

Paradoxically, it is often the desirable, wished-for freedom from violent, pathologizing constraint that the uncoupling of biology and culture can be seen to promise, which appears to put pressure on the distinction and seems responsible for conceptual slippage. As, perhaps, in this example: “It would certainly be easier if fewer aspects of life were gender-based. If school toilets and changing rooms were not arranged around gender”, Polly Carmichael, director of gender identity services at the Tavistock Clinic, argues (Carmichael, 2017). But what is it that the signs on public lavatories indicate? Gender or sex? And what is their furniture designed for? Social constructs or physical realities? My own gender has not prevented me from using toilets marked Male when the queue for the Ladies’ is intolerable, but my anatomy draws the line at a pissoir. I shall not go into the problems caused by incorrect use of the other type of toilet by the other type of anatomy. It is a simple if not very elegant instance of the difficulty with separating the body, its shapes and its needs, from gender. One of the informants for Richard Ekins and David King’s study of The Transgender Phenomenon makes the case more poignantly: “Practically and emotionally, becoming a man, physically, was the least difficult part of my role reassignment. It was, however, the most frustrating because it was only a compromise. I know that, however good the treatment, I’d never be fully male, functionally, anatomically or chromosomally” (Ekins & King, 2006, p. 47). 

The tension between the body, stubbornly limited and stubbornly resistant to our imaginings, and the anarchic, polymorphously perverse multitudinousness of the unconscious, in which we can be any shape we like and all the others too, perhaps amounts to psychoanalysis’s very own uncertainty principle (Heisenberg, 1927); it is never quite possible to fix on both precisely at the same time. They are of a different order. And make a problem of time itself, the passing of which is all too indelibly inscribed on the body but absent from the unconscious, dividing analytic focus on The Gender Conundrum into diachronic, developmental accounts this side of the Channel, and a synchronic, ahistorical approach to the structures of the mind and their interconnections on the other (Breen, 1993). Though even – perhaps especially – where, as in the Lacanian tradition, psychoanalysis attempts to liberate itself most radically from the body, where nothing in the unconscious is seen to accord with it, the body haunts psychoanalysis, suggests Andrew Parker in a paper also quoted by Breen. Leaning on Jane Gallop’s work, he  points out that “signification requires reference as its condition of possibility” (Parker, 1986, p. 101) – there can be no phallus without reference to the penis. The castration complex, “that privileged moment in which earlier experiences are reorganised and given special meaning, initiating the meaning of masculinity and femininity…, [this] ‘primal phantasy’ which organises phantasy life, irrespective of personal experience” (Breen, 1993, p. 20), relies on the existence of differently shaped bodies. Lacan himself makes the leap thus: “It can be said that this signifier [the phallus] is chosen because it is the most tangible element in the real of sexual copulation… It might also be said that, by virtue of its turgidity, it is the image of the vital flow as it is transmitted in generation” (Lacan, 1977, p. 287; emphasis added). 

Perhaps constructions of gender, and of identity beyond it, cannot but be haunted by the body too, notwithstanding cultural trends to the contrary. To illustrate, and because culture would seem to become a legitimate concern if gender identity is seen as its result, let me take those of you who have time to read ahead on a brief excursion into the world we live in. 

Even the most cursory survey of social trends would seem to suggest that much broader questions of identity, beyond gender, have been subject to exponential growth, and identity itself to an ever-greater division – divisiveness? fragmentation? – of models available. More than once, I wondered whether these might not be questions of Civilisation and its Discontents (Freud, S. 1930 [1929]) rather than identity or gender. 

And what are we to do with these trends? The enormous change in social conventions, the ‘current climate’, prevailing media interests and so on do not change our task, that is to understand the vicissitudes of this reality in conflict and repression, insists Donald Kaplan in a paper nearly 30 years old: “The actual variability of social reality is not the technical problem for psychoanalysis… More in keeping with the interests of the analytic method is the variability of uses to which social reality is put in neurogenesis… Transference is the realm of diagnosis for psychoanalysis” (1990, p. 8). What uses social reality might be put to is a matter for each individual analysis; no two are alike. Or as Freud put it to Abraham in 1915: “Anal-eroticism, castration complexes, etc are ubiquitous sources of excitation which must have their share in every clinical picture. One time, this is made from them, another time that. Naturally we have the task of ascertaining what is made from them, but the explanation of the disorder can only be found in the mechanism considered dynamically, topographically, and economically” (cited in: Stoller, 1968 [1984], p. 141).


 Gender identity development 

Individual development is precisely that. And not at all straight forward. Susan Coates thought it was “time to jettison the concept of developmental lines and replace it with a concept of multiple pathways that are very complexly determined” 20 years ago, believing this to be the case especially with regards to gender identity development (1997, p. 46). “Whatever sequences are observed in a particular domain must be simultaneously understood in the context of multiple transactions between self and other across different domains with consequences that cannot be predicted a priori" (ibid. p.45). Perhaps it is not necessary to jettison Anna Freud’s (1963) developmental lines altogether, but more a case of seeing them twine, twist, turn and snag together in ways not just unpredictable but unique. 

In this melee, gender might be “more usefully imagined as a function than simply as a structure…, as a way of doing various psychic and relational tasks in certain ways” (Harris, 2009, p. 102). Or as “a complex psychological construction centring on the body, interactions with the bodies of others, and the drives” (Dahl, 1988, p. 364); a complex interplay involving “physical sexual characters, mental sexual characters [and]… object choice which, up to a certain point, vary independently of one another, and are met with in different individuals in manifold permutations” (Freud, S. 1920, p. 170). It is not simply a case of “‘a feminine mind, bound therefore to love a man, but unhappily attached to a masculine body; a masculine mind, irresistibly attracted to women, but, alas! imprisoned in a feminine body’”, Freud observed with regards to popular ideas about homosexuality in 1920 (ibid. p. 170). Today, he might also have been talking about the ‘transgender phenomenon’. 

The development of manifold permutations, fulfilling a variety of psychic and relational tasks in ways that are themselves subject to both constant evolution and Nachträglichkeit is beyond my powers of exposition. In the best-case scenario, that of “common unhappiness” (Freud & Breuer, 1893-1895, p. 305), permutations of object choice and gender can be contained in bodies the shape and shade of which was given, and whose only evolution is, broadly speaking, towards decrepitude. The literally sharp end of gender identity development, the numbers of those who feel they cannot, in the bodies they have, ‘contradict themselves, be large and contain multitudes’, to slightly misquote Walt Whitman (1855 [2007], p. 67), and hence seek recourse to the surgeon’s knife, is still very small however. And themes appear to emerge in the equally small psychoanalytic literature on ‘atypical gender development’, ‘gender dysphoria’, or ‘gender identity disturbance’ – the choice of term can seem programmatic – which I shall try to outline instead. 

Though before my focus narrows, I will share with you a thought that kept coming back to me in relation to the other, no more than commonly miserable end. The end that can make anything LBGTQIA and gender fluid look like ‘the thing’, and sound like the loud and proud expression of a progressive politics which sets itself in opposition to the forces of reaction. To ‘anyone over 30’, reactionary by definition, past it, and past it especially where matters of sex are concerned; or gender. I wonder whether on this level gender is, perhaps for some, perhaps to an extent, ‘the new black’. Perhaps on this level, for the current generation of young people, gender fluidity is the ‘free love’ of 1960s ‘counter-culture’, the Sex Pistols’ 70s punk, “No Feelings”, “Never Mind the Bollocks” rejection of everything, or the gender-bending, sexually explicit antics of “Karma Chameleon”, the “Material Girl”, and Frankie Goes to Hollywood in the 80s: the employment of peers and popular culture – that “buddy effect” – in the service of managing adolescence’s most difficult developmental task. Perhaps the vehement, wholesale repudiation of the parent generation’s sexual mores, and a certain pleasure in scandalising its outdated sensibilities, have always played a role in helping young adults set themselves apart from oedipal fathers and mothers, above all sexually. And when every sexual taboo bar incest appears to have been broken already, in every available medium, gender has, perhaps, to be ‘the new sex’. 

And perhaps where this is not enough to separate and dis-identify the adolescent body from that of the object which will otherwise enslave it, dangerously, incestuously, or where no such separation can be contemplated at all, where the ‘final sexual organisation’ in which all bodies are potent becomes an either/or of survival, of one body or another, it is the body itself – and maybe not really its gender, but very much its sex – that must be altered, violently (Laufer & Laufer, 1989). Is the demand for a surgeon’s knife to ‘attack’ a healthy body in pursuit of gender reassignment categorically different from attacks on their bodies the adolescents in our consulting rooms carry out themselves, with blades, pills, drugs, food or no food, matches, motorbikes, you name it? 

Juliet Mitchell (2004) offers an interesting hypothesis about sexual difference, gender, and cultural trends. Stoller “notoriously” having taken sexuality out of gender by turning it into a sociological trope, she believes its meaning to have shifted again in recent decades to include once more the relationship between women and men; sex. Except not sex as in reproduction, the sort that even in this day and age requires two differently sexed bodies, or products thereof as a minimum, to result in pregnancy and child birth with both of those still and absolutely the sole preserve of female bodies. In her argument and by contrast, ‘gender’ “expresses a sexuality that is not primarily or predominantly procreative”. Indeed, the very “prevalence of gender as a concept… has come about because since the 1960s, dominant sexual modes in the West have been non-reproductive” (ibid. pp.67/68). This type of sexuality does not need sexual difference, and its excitements do not risk losing their erotic charge by being tied to biological necessity and the survival of the species. This type of sexuality, she suggests, might be heir to Freud’s radical undermining of the notion that there is anything ‘natural’ or ‘normal’ about sexual desire in the Three Essays (1905) – heir in radical, subversive nature, as well as heir to a heritage that keeps evolving. ‘Gender’, she says pithily, “is the polymorphously perverse child, grown up” (Mitchell, 2004, p. 73). And, might one add, not tethered by reproduction to a ‘final sexual organisation’ that must make reference to the oedipal parents of the primal scene and their differently shaped bodies? Mitchell sees “the perpetuation of … polymorphously perverse, non-reproductive sexuality tak[ing] place through lateral, not vertical relationships, starting with siblings”, pointing out that “the advent of a sibling (or awareness of the older other who is so like the emergent infantile subject) produces ecstasy along narcissistic lines and despair occasioned by the sense of annihilation, of being displaced/ replaced or just ‘not there’” (ibid. pp. 75/76, emphasis added). 

Are these the ecstasies and the agonies of the 21st century? The last frontier in a turning away from the primal scene and the ultimate subsuming of sexuality – now gender – into the narcissistic register? We will hear more about trajectories of narcissism and gender identity this afternoon. Though narcissism, and siblings too, have already featured in the psychoanalytic literature on atypical gender identity.


Atypical gender identity development


A certain overlap between gender identity disorder and both autism (de Vries, et al., 2010) and trauma (see for example: Coates & Moore, 1998) seems to exist, though as to the course an individual’s seemingly atypical gender identity development will take, the younger the child, the more difficult it is to predict the eventual outcome (Di Ceglie, 1998, p. 11). Gender identity disorder appears to persist into adolescence in only about 20% of pre-pubertal children (Di Ceglie, 2009, p. 6). In most children who present with gender variance between the ages of 8 and 12 but receive no mental health interventions, this will not continue beyond puberty; it is often the onset of puberty that marks the change. What might be responsible for desistance is unclear, though hormonal changes at puberty, exclusion from peers, and shifts in cognitive development have all been hypothesized as possible triggers (research cited in: Lament, 2014, p. 17). 

How easy is it, I wondered, in an age that struggles with ambiguity in the very act of promoting it, where gender fluidity is the collective term given to 114 mutually exclusive subdivisions, for parents to remember that small children may well want to be Postman Pat one day and Queen of England the next? To quote Susan Coates once more: “In development we are not seeing an inborn femininity or masculinity [or one of the 112 other varieties of gender] gradually unfold itself according to some prearranged plan, but rather a complex set of exchanges between self and other in which gender can take on a rich variety of meanings and gender performance can be put to a variety of usages” (1997, p. 49). 

The unconscious uses to which atypical gender identity is put in the course of development, so a survey of the psychoanalytic literature suggests, fall into two broad categories: issues of separation, and adaptations to what is perceived to be desired by the object. They are not, of course, unrelated, many of the reports from child analysts citing both alongside each other. I will attempt to give you a not altogether systematic, whistle-stop tour: It seems fitting to begin with Stoller’s work, although it is largely restricted to boys; gender identity disorder is still much more common in boys. Figures he cited in 1968, putting female ‘transsexualism’ at about one third to one eighth of the frequency in males, are not dissimilar to current estimates. A speculative explanation revolves around “the fact that almost everyone spends infancy in close contact with a female body (mother), so that if a disturbance in the process of identification should occur, it is more likely in the male child, who must give up or outgrow his identifications with a female, a task not required of female children” (1968, p.197). 

Another take on the preponderance of male-to-female transitioning, more cultural still than Stoller’s perhaps, was suggested by Angela Joyce who kindly read a draft of this paper (thank you!). Might it be that masculinity is in crisis in this post-feminist age, she wondered, and such ‘gender-bending’ an attempt to evade a masculinity that is compromised? 

Though let us return to Stoller for now: Mothers feature large in the stories he unearthed from ‘his’ boys, primarily as agents mitigating against separation on the most immediate level, between their own bodies and those of their sons. Women predisposed to appropriate their boys’ bodies by a certain ambivalence towards their own femininity turn these infants into “mother’s feminized phallus” (p.120), attached to her quite literally, skin to skin. An excessive identification with such a mother is the result not of anxiety, but of an endeavour to maintain a state of blissful symbiosis in which no sensual pleasure goes ungratified. It leads Stoller to feel that “this delay in permitting the boys to be free of their mothers’ bodies, of their constant cuddling and following eyes, … may be the primary pathology” (p.98). Fathers contribute with actual and/ or dynamic absence, and may be “not just … permitting the mothers to feminise their sons, [but] very subtly … pushing their sons back upon the mothers’ bodies” (pp.96/97). 

Ovesey & Person (1973) too, see ‘the transsexual phenomenon’ as a defence against threats to this kind of fusion, but emphasize fear more than bliss. Early separation anxiety, before there is proper self-object differentiation and menacing annihilation, is thought to be at its root. A later paper clarifies their belief that gender identification precedes the phallic-oedipal period (Person & Ovesey, 1983). Separation anxiety also appears centrally in an examination of “extreme boyhood feminity” (Coates & Person, 1985), here linked to uneven maternal availability. These boys, not sure their mothers want them – as themselves rather than for themselves – and pressed to find ways to keep her, settle for imitation. “[They] confuse being mother with having mother” (ibid., p.708). 

A study of 30 boys during the second year, in the early genital phase, revealed in the three found to be ‘more feminine’, to wear their mums’ jewellery and clothes and engage in elaborate doll play, greater castration anxiety and heightened aggression, as well as stronger attachment to and identification with mother (Galenson & Roiphe, 1980). With a particular kind of mother, or a mother experienced in a particular way; with a mother that threatens loss and whose loss is felt to be profoundly threatening. Focussing once again on the earliest stages of development, Coates, et al. (1991) make room for possible contributions from genetic factors, via the child’s temperament, but the theme of loss is also prominent in the unconscious economies they uncover. A kind of ‘triple whammy’, an awareness of gender difference in the absence of fully established self-object constancy, coupled with an experience of loss of mother, leads to a feminine identification designed to handle separation and annihilation anxiety, and to ward off aggression. Atypical gender identification is, essentially, a variant of identification with the lost object. We are still with boys and their mothers. 

Individual case reports from around the same time, of “Henry” (Roiphe, 1991) and “Billy” (McDevitt, 1995) for example, all make similar observations. An intergenerational component is particularly evident in Billy’s story, whose mother was ‘forced’ before him to woo parents she felt wanted not her by adopting the desired boy child’s gender behaviour; in relation to father, felt to prefer her (already) feminine sister, especially. In turn, she would have preferred a girl not Billy, and Billy ‘obliged’, maximising – in the absence of much of a father – his chances of being loved by ‘choosing’ his gender accordingly. It is a progression from his mother’s predicament in both meanings of the term, the identification with the parent whose loss is feared the main defence against it for both, magnified in Billy, one might say, by having to manage the ‘hand-me-down’ in addition to his own conflict. A mother felt to ignore and devalue her boy’s phallic urges breeds hostility. The resulting increase in castration anxiety further fuels an identification with her. 

A little earlier, Kirsten Dahl (1988) argued for greater complexity in the conceptualisation of gender identity development than the near-exclusive reliance on processes of identification and their vicissitudes. A child’s “failure to differentiate from a primary feminine matrix, contained in the symbiotic union between mother and child” (p.363), she considered not just too simple an explanation for ‘pathologies of gender’, but simply wrong. As well as an individual’s adaptation to external reality and social conventions, highly individual efforts to find compromise gratifications for instinctual drives are thought to contribute to gender construction. “Gender draws together”, she writes, “aspects of ego development and libidinally driven derivatives of infantile sexuality in the context of object relations, narcissism, and aggressive desires. The pathway to a final gender organisation [typical or not] is influenced by development along all of these lines in interaction with one another” (p.352). No two such pathways can possibly be the same. No two sets of fantasies – seen as expressions of the psychic effort involved – can possibly be the same, including fantasies of gender. 

With Dahl, we also get to the girls, finally. Or to a girl at least, “Marty”, a boy trapped in a girl’s body by her own account. Though no claims are made for her story to be representative. Indeed her story, like Billy’s and Henry’s and those of Stoller’s children, contains elements with which all of us will be familiar, whether we have ever seen a gender-dysphoric patient or not – trauma and loss, family difficulties of one kind or another, slights real or perceived, and so on. 

The longitudinal study of another girl, “Mia”, seen in various settings all the way from birth to adulthood (Olesker, 1998), again underlines the uniqueness of unconscious fantasy as it carefully follows her journey through intrapsychic conflict and compromise formation. While this journey too is like no other, the observation that her “masculine character formation” began early in the second year, before (properly oedipal) awareness of sexual difference, would seem to add weight to the more general point of gender preceding sex; to a ‘sexuality’ in the register of narcissism rather than tied to a primal scene. Rather strikingly, the parents of the primal scene Mia was yet to discover are said to have been ambivalent about the sex of their child from the start. For complex reasons of their own, they would have preferred the opposite. In this respect, Mia the girl’s story is the same as Billy’s and many of the other boys’. A later paper (Olesker, 2003) finds this to be so in all 5 cases examined: in each, the mothers wished for a child of the opposite sex – and treated the one they got in highly ambivalent ways. And in each case, the opposite sex sibling was seen as preferred. It would be a peculiar irony if sex were the victim, in some cases quite literally so, and gender the victor, of an effort to maximise love, to secure an object’s libidinal investment in a sexed and sexual body. 

It is, I will grant, a stretch of the imagination from an object’s lack of love for the child’s sexed body to insecure attachment, but still: 73% of boys with gender identity disorder have been found to be insecurely attached to their mothers (cited in: Zucker, 1998, p. 34). There is also an association, again for boys, between gender identity disorder and a composite index of maternal psychopathology (Zucker & Bradley, 1995). 

Domenico di Ceglie (1998), who has been working at the sharp end for decades, notes that these boys seem to experience separation from an attachment figure as a “psychological catastrophe”. This may be based on “an unsatisfactory relationship with the internalised breast and, in particular, temperamental characteristics such as inability to tolerate frustration”, leading the boy, via excessive splitting, to identify with an all-gratifying, idealised mother image to ward off disintegration and chaos. Psychic survival is ensured by disavowing aspects of reality – of the real, male body (p. 19/20). Girls, by contrast, may perceive the mother to be under threat – from depression, domestic violence, etc. – and attempt to ensure both hers and their own (psychic) survival with a similar disavowal, of a female body ‘too weak’ to protect mother; thus also guarding against separation. He too, like most other commentators, draws attention to the concreteness of these children’s functioning, ‘too afraid of fantasy to work out issues in play’ (Olesker, 1998). It is seen to be connected to gender identity development beginning early – when the ego is still largely a body ego is one formulation (Olesker, 2003) – thus pushing, where problems arise, concrete solutions. The relative capacity for symbol formation and symbolic thinking may both contribute to the rigidity of atypical gender organisations and correlate to its persistence, di Ceglie (2009) believes. 

A radically different approach to the ‘transgender phenomenon’ has appeared more recently, citing in its support the failure of both research and clinical experience to demonstrate convincingly any of the explanatory hypotheses advanced thus far (see for example studies cited in: Saketopoulou, 2014). Moreover, questions of aetiology are seen to “arise only when gender experience does not align with the body’s material surfaces”, implying a bias in psychoanalytic thinking that accepts normative gender identification at face value, while variations must argue their legitimacy (ibid. p. 775/776). Treating the gender of transsexual children not as symptom, but as a viable subjective reality, as is suggested, turns the focus of previous lines of enquiry inside out: rather than understanding the meaning of fantasies of gender, it becomes a question of “try[ing] to comprehend how unconscious fantasy may be mobilised to manage the painful experience of gender/body mismatch once it has been formed” (ibid. p.776). Thus, the fantasy of being born into the wrong body, rather than giving rise to it, can be seen as a solution to a painful discontinuity between body and gender experience. Rather than possible contributions to this pain from childhood trauma, it is the child’s traumatisation by primary objects who “misgender” it, insisting on its natal sex despite the child’s explicit articulation of a different identity due to “gender-inflected body-dysphoria” – this may present as early as age two or three – that requires attention (ibid. p. 779). 

An entire volume of The Psychoanalytic Study of the Child was dedicated to these ‘conundrums and controversies’ in 2014. It begins with a carefully argued plea for “Listening and Learning from Gender Non-Conforming Children” by Diane Ehrensaft (2014). Very broadly in line with Saketopoulou, she makes a case for therapeutic work to take account of the fact that “the most common form of trauma [gender non-conforming children] present is usually a consequence rather than a cause of their gender nonconformity, typically a result of parental or social rejection, harassment, and bullying” (p.42). From this view, that non-acceptance of the child’s “unique gender web” is the greatest source of psychic pain, follow two things: “collaboration with [all] parties active in the child’s life becomes an essential component of the [treatment] process” (p.44) and, not essentially but quite possibly, medical interventions such as hormone blocking to delay puberty. Her case example, “Jacqueline/Thomas”, who began to complain about being a girl in pre-school and started therapy at 9, follows this trajectory. 

Some of her discussants detect a contradiction between Ehrensaft’s view of gender as mutable throughout life, and her notion of a ‘true gender self’ that may be uncovered in what she calls True Gender Self Therapy (Weinstein & Wallerstein, 2014). All of them emphasize the continuous evolution of who we are, based on a complex interplay of nature, nurture, and culture. From this position of on-going development, they question the advisability of preventing what might become of it at puberty with hormone blockers (Knight, 2014), and the level of autonomy over their bodily development that Ehrensaft is felt to imply should be given to young children (Brinich, 2014). I could not help noticing something else in the description of Jacqueline/Thomas’s ‘gender history’ and treatment. Conceived using a sperm donor and born to a mother “delighted to have a girl”, no male figure, fantasied or real, makes an appearance anywhere in the detailed account of the child’s background and therapy – except in the name Ehrensaft gives to mother: “Adrian”. And in Jacqueline/Thomas’s wish to be a boy. I will leave you with this thought. 



If I were to try and summarise what I have learned from a year reading up on atypical gender identity development, and without relevant clinical experience of my own, it would amount to this hunch: parents’ unconscious needs and wishes are somehow crucial. That gender identity begins to be forged pre-oedipally, without reference to castration and sexual difference proper, but in relation to objects whose understanding of and investment in the bodies of their infants includes both, to whom the sex of their child has meaning, for better or for worse, and before it makes any sense to the child, seems to me somehow important. Might it not be that if the ‘enigmatic message’ conveyed to the infant is not just sexual beyond its comprehension (Laplanche, 1997), but ambivalent about its sex, this might mitigate against an investment in the sexed body – one of the two models – it has? And might not, in the child’s effort to maximise love, this sexed body fall victim to a construction of gender that need not refer to it? 

Incidentally, if these constructions persist, so it can appear, sex may be ‘sacrificed’ altogether. Reading through more than half a century’s worth of testimony by and about transgendered people (in Ekins & King, 2006), it is striking how very little sex – of the erotic rather than the biological variety – there is. Though, as the authors caution, this may have been due to a perceived need to keep ‘perverse’ desires secret and collude with a ‘sanitised’ medical model of gender dysphoria that offers reassignment as cure; it might change. 

Like so much. In the end, we can only really understand how a particular child constructs gender, and keeps constructing it, through all phases of development, amidst the prevailing cultural winds and from inside a body that has definite limits and definitely limits, by following the twists and turns, and the travails, of its unique unconscious elaborations. 

We are all born naked. The rest isn’t drag but a drag, I’d say, for some of us more than others.






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