An undermined therapeutic alliance: A case study

Abstract

Seeking help and assistance can prove to be a frustrating experience for intersex individuals: physicians and psychologists can be misinformed about variations of sex characteristics (VSC) and their practice may have a detrimental effect on the physical and psychological wellbeing of individuals with VSC. This paper focuses on how previous negative experiences, such as early genital cosmetic surgery and unaware clinical management, could negatively affect psychotherapeutic relationships. Its principal aims are to: 1) identify which elements in clinical management of VSC may cause difficulties in building a therapeutic alliance and 2) identify which elements may promote the construction and reinforcement of the therapeutic alliance, even when a patient’s trust has been damaged by previous negative experiences. In order to explore the psychotherapeutic process with specific regard to the building of the therapeutic alliance, we report a case study whose subject is a 32-year-old man who sought legal advice for his sex reassignment process and began a brief supportive psychotherapeutic treatment. Roberto, the subject of this study, was born with VSC, was assigned the female gender and underwent genital surgery at birth. In his early childhood, he developed a male gender identity. Whenever Roberto reflected on the genital surgery that he had undergone at birth, anger and frustration pervaded his psychotherapy sessions and made it difficult to build a therapeutic alliance. However, it was possible to support Roberto in redirecting these negative affects, helping him to process them, build a therapeutic alliance, and benefit from a positive and trusting therapeutic relationship.

Keywords:

• intersex
• disorders of sex development (DSD)
• variations of sex characteristics (VSC)
• therapeutic alliance
• emotions in therapy
• intersex management

Disclosure statement

The authors declare that there is no conflict of interest and that no external funding sources were utilised for this study.

Notes

1. The high degree of variability in the combination of different sex characteristics leaves the door open to results that fall outside the binary concept of sex and outside the terms male/female (Crocetti, 2013; Hughes et al., 2006; Monro et al., 2019). To date, in the medical field, any atypical sex characteristics are officially identified with the term ‘Disorder of Sex Development (DSD)’, which identifies ‹‹congenital conditions in which chromosomal, gonadal, or anatomical sex development is atypical›› (Hughes et al., 2006, p. 554); according to the definition of DSD, atypical sex characteristics are evaluated as pathological deviations from a binary norm, regardless of the actual need for medical/surgical procedures related to the single cases (Crocetti, 2013; Monro et al., 2017). Despite this medical terminology – intended to simplify scientific communication – (Ahmed et al., 2016; Feder, 2014), the use of the term DSD has been questioned because it is seen as leading to the widespread pathologization of intersex people (Carpenter, 2016; Clune-Taylor, 2010; Crocetti, 2013; Davis et al., 2015; Lundberg, Hegarty, & Roen, 2018; Reis, 2007). The term ‘intersex’ is an umbrella term that refers to many different conditions (e.g. Congenital Adrenal Hyperplasia (CAH), Androgen Insensitivity Syndrome (AIS), Micropenis, Klinefelter’s Syndrome and Turner’s Syndrome); although it is widely used, the term ‘intersex’ has been criticised by advocacy organisations (Organization Intersex International (OII, 2012) and is not accepted by all people with this condition: ‘some people consider the label intersex as central to their sense of self; for others it holds no personal relevance, and yet others see it as incorrect and even deeply offensive’ (Karkazis, 2008, p. 18). The crucial point is that different people can have very diverse experiences of their variation and, even if it would be theoretically consistent to define them as intersex individuals, it may be found that they themselves don’t identify as intersex (Davis, 2014; Lundberg et al., 2018). In the literature, various authors have suggested focusing on certain positive aspects and considering intersex as a predictable variation of sex characteristics (Human Right Human Rights Watch, 2017; Preves, 2003); they have also proposed substituting the term DSD with non-pathologizing terms such as: divergences of sex development (Reis, 2007; Schweizer, Brunner, Handford, & Richter-Appelt, 2013), diverse sex development (dsd) (Liao & Simmonds, 2014), or Differences of Sex Development (DSD) (Tamar-Mattis, Baratz, Baratz Dalke, & Karkazis, 2013). That said, none of the proposed alternatives has reached a wide enough consensus to be deemed as meaningful. Throughout this paper the terms ‘intersex’ and ‘Variations of Sex Characteristics (VSC)’ will be used; the term VSC emphasises that a reference is made to foreseeable conditions. Furthermore, as Monro et al. (2017) highlighted, although the term ‘intersex’ also includes people with Variations of Sex Characteristics (VSC), some individuals prefer to be addressed by naming their specific diagnosis, so the term ‘intersex’ should be used cautiously; indeed, more and more people decide to employ terms that grant their identity a certain degree of social flexibility (Hughes et al., 2006; Lundberg et al., 2018), and this, as a consequence, places the focus on the essential goal of promoting wellbeing (Davis et al., 2015) and on the ability for health professionals to develop ‹‹a personalised diagnosis-specific vocabulary›› (Cools et al., 2018, p. 418).

Additional information

Notes on contributors

Paola Miano

Paola Miano is an Associate Professor at the University of Palermo - Department of Psychology, Educational Science and Human Movement. Viale delle Scienze - edificio 15, 90128 Palermo – ITALY. Tel:[phone]; email: [email protected] Her research interests include gender, dysfunctional families, sexual abuse and attachment. ORCID: 0000-0002-1969-8731

Gaia Di Salvo

Gaia Di Salvo is a psychologist interested in gender identity issues, sex development and sexual orientation, currently involved as volunteer for Arcigay Palermo. Professional address: Via Boris Giuliano, 32, 90144 Palermo – ITALY. email: [email protected]

Massimo Lavaggi

Massimo Lavaggi is a psychologist and psychotherapist specialised in cognitive and behavioural psychotherapy and EMDR. He carries out psychodiagnostic evaluation, psychological counselling and individual and couples psychotherapy for adolescents and adults. Professional address: Associazione Consultorio Transgenere Via dell’Aquila, 27/2, 55049 Torre del Lago Puccini (Lucca) – ITALY. Tel:[phone]; email: [email protected]