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Gender identity disorder: creative? Adaptive? Or absurd?

Marilyn Wilchesky Helene Cote
Head, Gender Programme Clinical Sexologist, Sexoanalyst
Human Sexuality Unit Human Sexuality Unit
Montreal General Hospital Montreal General Hospital
Montreal, Quebec Montreal, Quebec

ABSTRACT: Although applicants for sex reassignment surgery show little evidence of psychopathology, the denial of reality manifested by some gender dysphoric individuals can make therapists unsure whether reassignment is the best way for these clients to overcome their severe distress at being "trapped in the wrong body". In our work with such individuals, we explore fantasy material to better understand their imaginary processes. We have observed that individuals on the mild to moderate end of the gender identity disorder continuum evidence a flow from secondary process to primary process thinking. If temporary, the denial involved in this regression into primary process thinking may be adaptive in that it provides a haven during a period of trauma. Those on the more severe end of the continuum remain fixed in this regression. This paper reviews the rationale for and application of this sexoanalytic approach in the diagnosis and treatment of gender dysphoria.

Key words: Gender identity disorder Primary and secondary process Denial Regression in the service of the ego (REGO)


A number of studies indicate that people with gender identity disorder show little or no evidence of psychopathology (Amias-Wilchesky, 1995; Cohen-Kettenis, Cohen, & de Ruyter, 1993; Cole, Emory, Boyle, & Meyer, 1993; Gonzales-Heydich, Van Massdam, Gould, & Laub, 1993; Pfafflin, 1993; Stoller, 1968; 1975; 1985). From a psychodynamic perspective, Beitel (1985) noted only limited psychopathology in people with this disorder; he proposed that the gender identity part of the self is split off during psychosexual development. Lothstein (1979) suggested that the child with gender identity disorder is healthy except for the gender identity confusion (a situation caused by the mother being strongly bonded to this child in every respect except for gender identity). Some authors have suggested that narcissistic features can be found in this population (Cohen, 1991; Langevin, 1985; Sorensen & Hertoft, 1982; Volkan, 1979), while there is some support that they manifest a borderline personality organization (Cohen, 1991; Beitel, 1985; Lothstein, 1983; Volkan, 1979; Meyer, 1976; Meyer, 1974; Person & Ovesey, 1974).

The gender patients with whom we work are, for the most part, well-functioning vocationally, with good object relations in their environment. However, this may reflect our selection criteria both for entry into our programme and into its offshoot, the Cross-Roads Group. Given these observations, and the lack of evidence of psychopathology described above, what is the source of our nagging doubt about some of the gender dysphoric patients who apply for sex reassignment surgery? Among a certain group of this population, there seems to be a common thread of massive denial of reality, a denial that extends to all aspects of their lives and includes a refusal to acknowledge the inevitable losses, such as employment, family members and significant others, that are likely to accompany the transition. This disavowal by some gender dysphoric patients goes hand in hand with their traditional resistance to treatment and their unwillingness to look inward (which carries the risk that s/he would be compelled to face reality). We are struck by the compelling force (articulated as a search for inner harmony) that leads these individuals to seek a drastic solution (sex reassignment surgery), a solution that also requires of them an enormous investment in a potentially pathological defence mechanism.


Freud (1938) described denial as a defensive structure used by the person to refuse to recognize the reality of a traumatizing perception, particularly that of penis absence in women. In Freud's view, this defence was specifically at the root of fetishism. During early psychosexual development, denial was considered benign, but when carried into adulthood, this mechanism was seen to be the starting point of psychosis. He saw the origins of neurosis in repression of the id's needs, and of psychosis in the denial of reality.

The conflict between two irreconcilable differences, between denial and recognition of feminine castration, engenders a splitting within the individual. The formation of a compromise between these two conflicting positions is one way of protecting the self from anxiety. Freud differentiates normal neurotic repression, which protects against conflicts between the id (impulses) and the ego (self), and denial, in which the ego defends against external reality (Laplanche & Pontalis, 1984). In contrast to Freud's notion of allowing one pole into the conscious, while the contradictory component is retained in the unconscious, Kohut (1971) offered the concept of a vertical splitting of the ego either through disavowal of reality (the penisless person) or through the sphere of suspended reality testing (creating, for example, the phallic woman).

The earliest defence mechanisms of the ego are based on primary processes, while the experience gained by the person from his primary processes helps him elaborate the defence mechanisms. These are further refined, sophisticated, and ruled by the ego (Sandler & Freud, 1985).

Just as Freud had described that dreams are the ideal pathway to the unconscious, we have been using fantasy material to access our gender identity disordered patients' deeper processes. The function of fantasy is to create and facilitate intrapsychic links between the instinctual drive and the object, through which the conflicts of ambivalence can be elaborated (Perron-Borelli, 1994). For us, one example of the denial or unreal reality evidenced by some gender dysphoric patients would be the 47 year old, 6'2", "tank-like" figure, originally male, but dressed as a woman, who claims that his spouse, all his children, parents, and workplace will accept his new presentation, and that he will have no difficulty doing the two-year real-life test that must precede sex reassignment surgery. It is this kind of massive break with reality, albeit within a tightly circumscribed area, that has led us to a closer inspection of fantasy processes and gender ambivalence in gender dysphoric patients.

The mechanisms responsible for transforming the real into the unreal are the primary and secondary thought processes. The primary psychic process are the principles regulating unconscious processes. These refer to a type of thinking typical of childhood and of dreams. In brief, one finds primary process in the early cognition patterns of children, in the dreams of young and old alike, and in psychotics. The primary process is the domain of the id (impulses), while it is the ego (self) which regulates the secondary process (Boris, 1989; Fenichel, 1945). This regulation is needed, it is argued, so that the intensity of the urge is not overwhelming. The ego's chief function is to inhibit primary process by neutralizing, or discharging, the energy (e.g., energy in the form of libidinal, aggressive, or anal content (Laplanche & Pontalis, 1984). (We note the connection of this view to Freud's pleasure principle.)

The secondary psychic process is the mechanisms governing the preconscious ego. It is the logical thinking by which the ego regulates external stimuli (e.g., by deciding how self-preservation would best be served). Self-preservation might require avoidance of the stimuli, either by changing the external reality or adapting the self. The ego manages internal instinctual demands by determining when or whether they should be satisfied or ignored. This ego regulates the initial desire for immediate gratification, using judgment, logic and reality-testing (Campbell, 1981). Freud described as pathological those defence mechanisms in which the ego has been overtaken by the primary process (Fenichel, 1945). It used to be assumed that the development of the secondary process was dependent on the "differentiation of the ego from the id" (Lampl-de Groot, 1965). Ego psychologists, such as Holt (1967), believed that primary process thinking does not exist at birth, but develops in parallel to the secondary process. It evolves as the child seeks to fulfil its needs by resorting to temporary regression.

While primary process thinking is predominantly unconscious (in contrast to the consciousness of secondary process thinking), primary process thinking does filter through into consciousness. A good example of this crossover is the association of creativity and primary process (Arieti, 1976; Dudek, 1980, in Russ, 1988; Freud, 1915; Kris, 1952). In adults, this "raw" level of thinking (primary process) is not limited to psychotic thought, but is also present in creative mental functioning. Access to the mobility of ideas allows for new links to be made to traditional concepts. The healthy ego can relax to produce artistic creativity and humour. This controlled reversion to primary process magical thinking (i.e., a temporary willingness to abandon normal constraints), has been called by Kris (in Holt, 1970) regression in the service of the ego (REGO). Kris describes two phases of regression: inspiration, in which the normally hidden drives and impulses surface; and elaboration, in which the primary process is harnessed by the ego, rather than having the self overwhelmed by it, as is the case in the psychotic condition. Holt (1970) has clarified these two types of regression as respectively adaptive and maladaptive.


Applicants for psychological, hormonal and surgical gender reassignment are not homogenous; they represent a continuum of severity of gender identity disorder (see Figure 1). The patients on the moderate end of this spectrum seem to have temporary lapses into primary process thinking, while those on the more severe end tend to be fixed in this regressive flow. We refer to the two groups as "Moderate Softcore GID" and "Severe Hardcore GID" (Figure 2).

Our own clinical experience is consistent with the concept of a continuum of gender identity disorder. The earlier a person remembers wanting to be or feeling like the other sex, the more firmly it is fixed. For example, for a small group of men and for most of the biological women with whom we work in groups, the consciousness of feeling like the other gender dates as far back as language development. For these patients in adulthood, the hard core gender identity disorder is encrusted in the cloak of denial. On the other hand, later onset of these feelings and wishes tends to correlate with a fluctuating gender identity confusion, what we describe in Figure 2 as the soft core GID person. These individuals will be much more open to introspection and to self-revealing exploration of fantasy material; for this group of patients, regression is indeed in the service of the ego (adaptive). The unfettered nature of the thought processes provides fertile soil for working on the ambivalence. Such individuals show clear swings from reality to fantasy and back again during treatment.

Our use of fantasy material in treatment and diagnosis (see also Cote and Wilchesky, 1996) allows us to move easily between the unconscious and conscious. In this way, we can access insights beyond the physical and psychological images that our patients are ready to project. Their different levels of imaginary operations become apparent. The regression from secondary process thinking, to primary, and back, is most common in the ambivalent group; the rigidly defended fixed core gender identity group are comparatively unmovable in this respect.


Boris (1989) suggests that psychoanalysis is about representations: images, signs and signals. There is a world in which things and events are as they are: they are real. A person's secondary process thinking can be trained and disciplined to perceive things and events accurately, to remember them clearly, and to recall them faithfully. A person can use this capacity for secondary process thinking to learn how to think dispassionately. People also have an active capacity for primary process thinking; its relationship to reality occurs through imagination. Primary process represents, rather than records; it does not discover, but invents. Instead of recalling, it presents anew the old images which have been deformed by craving and anxiety. This primitive cognitive process is awash with perceptions, fantasies and memories.

Working with gender dysphoric patients in this flow between reality and fantasy, we hope to maintain easy passage between the primary and secondary processes, thereby facilitating regression in the service of the ego, rather than in its disservice. We propose that the core GID patient becomes fixed in the fantasy ("I am a woman in a man's body"), and only accepts the reality which suits her or him. In our work with a selected group of patients (i.e., those with ambivalent or soft core GID's), we use fantasy material to focus on the flow and plasticity of the person's thought processes. In so doing, we help them to consider solutions other than actual gender reassignment.

In conclusion, in spite of the fact that all patients present with the same request, it should be remembered that there are different levels of GID in both men and women. Using a more finely-tuned diagnostic grid for the Gender Identity Disorder Syndrome could facilitate a different treatment approach, which can result in withdrawal of gender identity reversal.
COPYRIGHT 1996 SIECCAN, The Sex Information and Education Council of Canada
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Author:Marilyn Wilchesky; Helene Cote
Publication:The Canadian Journal of Human Sexuality
Date:Jan 1, 1996
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