An Introduction to the Papers – Clinical Contributions on Gender

ABSTRACT

The Co-Editors-in-Chief of The Psychoanalytic Study of the Child introduce two clinical papers on Gender Dysphoria which include detailed clinical material from the analyses of four children born biologically female. They emphasize the importance of a psychoanalytic developmental theory as a foundation for analytic work with children and adolescents, and promote the idea of ongoing conversations in our field regarding these complicated issues. They encourage readers to reflect on the analytic material with a curious mind and an attitude of not knowing, to further their own insights into the complicated issue of gender and Gender Dysphoria and to contribute to the conversation.

KEYWORDS:

• Gender dysphoria
• gender role identity
• gender fluidity
• child psychoanalysis
• development

In 2003 The Psychoanalytic Study of the Child published a section of papers on the topic of gender in which a group of psychoanalysts studied five analytic cases in-depth with issues related to this topic. Wendy Olesker introduced the section with her paper “Gender and its Clinical Manifestations” (2003), describing how this work was informed, directly and indirectly, by contemporary views of development. This viewpoint was reiterated by Claudia Lament in her introduction to the 2014 section titled “Transgender children: Conundrums and controversies,” where the investigation and target of the study of these children was “primarily, though not exclusively, through the lens of the psychoanalytic developmental point of view” that included “complementary dimensions of linear and nonlinear progressive hierarchical growth” (p.15). It is this developmental viewpoint that is at the core of child and adolescent psychoanalysis. While there is much we have learned, we still have a way to go. As Anna Freud (1979) proposed during the later years of her life, “the next rewarding trend of child analytic work” (p. 136) is “the study of various ego mechanisms and how they developed; disharmonies between lines of developmental, as well as between and within internal agencies; the impact of constitutional factors; the rate of structurization; environmental influences; and a more detailed examination of the developmental lines themselves” (Miller 1996, p. 165–166).

It is this increasingly complicated developmental viewpoint to which the Editors of the Psychoanalytic Study of the Child are committed, as well as to maintaining the aim of stimulating ongoing “conversations” among readers and authors. As Lament (2014) concluded: “It is incumbent upon our child analytic community as stewards of what is developmental in all of its contemporary domains to press for continuing dialogue about the transgender child” (p. 24–25). A continuation and expansion of this dialogue occurred in a subsequent section of papers in 2022 titled “Transgender children: From controversy to dialogue” introduced by Jordan Osserman and Hanna Wallerstein. The same idea was echoed by Avgi Saketopoulou (2020) who called for “conversations about what we are learning from our patients” (p. 1021), asserting that the subject of exploration should not be why but how any patient is trans or otherwise gendered. Among the tensions Osserman and Wallerstein (2022) identified as emerging in discussions with contributors to their 2022 section were those between the “particularities of childhood and more general ways of thinking about gender experience” including: 1) the child’s dependent status and the question of biological interventions (p. 166); 2) exploring the meaning and “why” questions in relation to a child’s gender expression in ways that can “expand listening and invite curiosity and elaboration without pushing a child to an explanation that leads to a gender normative position (p. 167); and 3) tension between affirmation or neutrality in responding to patients’ identifications. A third alternative to the tension between affirmation and neutrality, they proposed, is “acceptance” of patients’ statements about themselves “as a first step toward further thinking,” but they humbly acknowledge that “actual acceptance of what our patients bring us, perhaps akin to actual curiosity, is much easier to speak about than implement, especially within an arena as charged as gender” (Saketopoulou, 2022, p. 168). Saketopoulou (2020, 2022) emphasized that a trans patient’s vulnerability to the analyst requires one to pay critical attention to countertransference and deeply rooted body and gender anxieties if one is to undertake this work.

Olesker began her 2003 paper saying, “Gender issues, of great concern to many of our patients, are subject to much controversy” (p. 4). These controversies persist as Saketopoulou stated, “The world, and our field, is realizing we had imagined gender too narrowly. Changes to gender are outpacing psychoanalytic theory’s ability to keep up” (2020, p. 1020). Within contemporary psychoanalysis a greater number of youths are entering treatment with concerns about their gender, be it gender dysphoria, gender variance, or whether they identify as gender hybrid, gender queer, or gender fluid. While some may question whether these children are really in need of treatment, and if so what kind and with what aims, we remain committed to a point of view where both conceptualization and techniques are based on a psychoanalytic understanding of the child and the child’s development, and that analysis proper is the whole range of therapeutic possibilities kept available for the patient (Sandler, Kennedy, and Tyson 1980) within the multi-dimensional child-analyst relationship. In fact, any patient may profit from exploring gender-related matters as part of coming to fuller self-understanding. At the same time, it is important to understand that at the end of a child’s analysis (or anyone’s really), there is no way to know what the future holds and the impact it will have on the child’s world, be it internally, externally, or both. There is also no way of knowing what vicissitudes may play a part in subsequent gender identifications. We can’t and need not predict, but analysis offers a place to explore in a given time frame and opens up the child’s path for future development.

With the aim of promoting an open dialogue to the wider issue of gender in all its forms, the two papers that follow detail the psychoanalyses of four children born biologically female. Meisel presents two six-year-old girls, neither of whom thought they were or wanted to be boys but were unhappy with their gender. Analyzed many years apart, prior to and after the women’s movement of the 1970s, one was a child of the late 1950s and hyper-feminine, while the other, born in the 1990s, was anti-feminine. Beatrice describes the analyses of two patients, one age five and the other age 11, both self-described as boys. These papers offer us a unique opportunity. Both analysts listened carefully, seemingly without conscious bias, and worked within the analytic relationship. All provide clinical material, our unique data, necessary to advance our understanding of individuals’ experiences of having a mind, living in a body, in a family, and in a large social surround. They experienced cross-gender identifications, something that within psychoanalytic developmental theory is not in and of itself a sign of disturbance. Rather, as Knight discusses in her (2014) paper, “they reflect the expectable disequilibrium of self structures that gives the child the chance to play with different possibilities of gender role identity. As structures remain fluid and discontinuous in growth, so a child’s internal sense of her gender identifications mirror that same fluidity” (Lament 2014, 16). The conceptualizations and technical orientation offered by the authors reflect the times in which the patients were analyzed. Beatrice considers literature that influenced him at the time, taking us back to the origins of the psychoanalytic theory of gender. The reader is encouraged to reflect on the analytic material with an open mind and an attitude of not knowing, to further their own insights into the complicated issue of gender and Gender Dysphoria and to contribute to the conversation.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Jill M. Miller

Jill M. Miller, PhD is a child, adolescent, and adult psychoanalyst in private practice in Washington DC and the Past President of the Association for Child Psychoanalysis. She is a Faculty Member and Training and Supervising Analyst at the Washington Baltimore Institute, and a Supervising Analyst for child and adolescent candidates at several other Institutes. She has written on the work of both Anna Freud and Hansi Kennedy, children’s development of insight, the mind of the child analyst, and other issues related to child analytic technique. She is Co-Editor-in-Chief of The Psychoanalytic Study of the Child.

Denia Barrett

Denia Barrett, MSW is on the faculty of the Chicago Psychoanalytic Institute and has a private practice in Chicago, Illinois. She is a child and adolescent supervising analyst in Chicago, as well as a geographic rule supervisor at a number of other institutes. She has written on clinical work, working with parents, theory, supervision, and ethics. She is a past president of the Association for Child Psychoanalysis and is Co-Editor-in-Chief of The Psychoanalytic Study of the Child.