Gender Identity Disorder and Object Loss

Gender Identity Disorder and Object Loss EFRAIN BLEIBERG, M.D., LINDA JACKSON, M.D.,

AND

JACK L. ROSS, M.D.

Currentpsychoanalytic and nonpsychoanalytic views on gender identitydevelopment are reviewed and contrasted. Particular emphasis is placed on the roleof intrapsychic conflict and early object loss as determinants of disturbances of gender identity. Based on the concurrent hospital and psychoanalytic treatment of a latency-age boy, we advance the hypothesis that some boys who appear to be in the process of crystallizing a feminine gender identitymay basetheir wish to become a woman on heightened narcissistic defenses against early object loss and the associated experiences of helplessness and vulnerability. Such children may respond to psychodynamic treatment not specifically designed to alter gender role behavior but to resolve their pathological defenses and reinstate them on the path of growth and development. Journal of the American Academy of Child Psychiatry, 25, 1:58-67, 1986.

Life stubbornly refuses to conform to neatly ordered theoretical schemes. The complexity of psychological development makes it impossible to sort out individual factors and demonstrate that they alone produce certain psychological or symptomatic configurations. Overdetermination, as Freud (1893-1895, 1900) suggests, is the rule. Nevertheless, it is both clinically and theoretically useful to ascertain, as much as possible, the role of specific factors in normal and pathological development. In this paper, we will examine the link between early experiences of loss, the child's efforts to deal with the related traumatic experiences through heightened narcissistic defenses, and a pattern of gender identity disturbance. While gender identity has aroused a great deal of interest and controversy in the psychiatric, psychoanalytic, and psychological literature, most contributions rest on retrospective data collected in the treatment or assessment of adults. Few reports outline gender identity, particularly gender identity disorders, as they unfold in children. A latency-age boy whose wish to become a girl had begun to crystallize into a feminine identity provided us with a unique window into the development of a particular pattern of disturbed gender identity. The clinical material obtained in this boy's concurrent hospital and psychoanalytic treatment serves as a basis to discuss current views on gender identity development and advance a developmental and dynamic

hypothesis on a particular pattern of gender identity distortion.

Case History and Hospital Treatment Jay was adopted when he was 3 months old. Nothing is known of his biological parents or his early life, but his adoptive father recalls that when he first met him, Jay was a healthy, yet stiff-looking baby who smiled easily and cried little. His appetite was insatiable but he had trouble digesting milk and months went by until an acceptable formula was found. He seemed, nevertheless, to adjust quickly and well to his adoptive family and thrived under the care of his parents. The sudden death of Jay's adoptive mother when he was 13 months old was a brutal reencounter with the experience of loss. It was also a blow to Jay's adoptive father who was devastated by the loss of his wife. Since he traveled frequently, Jay's adoptive father left the child under the care of his maternal grandparents. Grandmother anxiously held on to the child. Grieving her daughter's death and wishing to keep her memory alive, grandmother encouraged Jay to dress in the shoes and clothes of the deceased mother. She also provided him with dolls and cooking utensils for play. Gradually, Jay and his grandmother were drawn together in a tight web that seriously limited their independent functioning. Jay was grandmother's "only reason to live." He was the "apple of grandmother's eye" who was both the ruler of the household and the recipient of her most tender ministrations. A new traumatic loss was in store for Jay. When he was 21/ 2 years old, Jay's adoptive father became involved with a woman and made plans for a new marriage. The child was removed from grandmother's care and placed with father and his new wife. It was

Dr. Bleiberg is Staff Psychiatrist and Director, Career Training Program in Child Psychiatry, The Menninger Foundation, Topeka, Kansas; Dr. Jackson is Staff Psychiatrist and Director, Outpatient Services, The Children's Division, The Menninger Foundation, Topeka, Kansas, and Dr. Ross is Training and Supervising Analyst and Director, Topeka Institute for Psychoanalysis, The Menninger Foundation, Topeka, Kansas. Reprints may be requested from Dr. Bleiberg, The Menninger Foundation, P.O. Box 829, Topeka, KS 66601. 0002-7138/86/2501-0058 $02.00/0 © 1986 by the American Academy of Child Psychiatry, 58

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then that the child first manifested symptomatic behavior. Jay did not wait long before setting the stage for an unending series of confrontations with his stepmother. He openly rejected any signs of affection from her and defied all of her attempts to set limits on him. Terrible temper tantrums became the rule when his wishes or efforts to be in control were frustrated. These tantrums were furious fits of screaming, spitting, kicking, tearing his clothes and destroying furniture. A selfdestructive aspect became increasingly more prominent, in the form of headbanging, scratching himself, pulling his hair out or biting his own hands. He also began to hurt the family pet, devising increasingly more cruel and harmful schemes to injure the dog or his stepmother. When he began nursery school at age 5, Jay's teacher described him as a provocative and destructive youngster with an unusual skill to zero in on people's weak spots. At home, Jay's parents were alarmed by a surge of compulsive masturbation "to the point of wearing out his pants" and an intensified preference for feminine dress and play. Finally, feeling exhausted after several failed attempts at outpatient treatment, Jay's parents requested hospitalization for the child. Diagnostic Assessment

When Jay was first seen for a diagnostic evaluation at the Children's Hospital, he was described as a short, slender, elfish-looking, effeminate 6-year-old boy who appeared much younger than his stated age. Never at a loss for words or ideas, his adultlike expressions and overly exact choice of words made him sound like a miniature grown-up. In contrast to his fragile appearance, he was cool and canny far beyond his age. He impressed the diagnostic team with his generous supply of intelligence, his charm, and his shrewd awareness of the right buttons to push to elicit responses from the environment. Jay's verbal cleverness, albeit charming and convincing, seemed more a means of manipulation and exhibitionism and a weapon to avoid closeness than a vehicle to effectively communicate thoughts and feelings. Jay did not miss opportunities to play with dolls and to pretend he was a girl. He openly stated his preference to be a girl and his conviction that he could grow up to become a woman, get married and have babies. Jay insisted on being in charge of his own and everyone else's affairs. Indeed, his heightened awareness of interpersonal nuances and his exceptional charm allowed him to be a most effective manipulator. However, when things did not go his way, he became anxious, loud, and aggressive. He met efforts to set limits with furious tantrums. When stressed, Jay's

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effeminate manners became more pronounced and his insistence on dressing like a girl escalated. Psychological testing reported above-average intelligence with some lag in perceptual-motor development. A most striking finding was the child's emotional isolation. He deeply mistrusted and devalued other people and kept everyone at arm's length. He did not experience other people as reliable and consistent protectors, soothers, limit-setters, sources of support or effective interpreters of reality. For him, however, this inability to trust was not a matter for grief or regret, but instead was the rationale for his efforts to hold on to an illusion of self-sufficiency and his attempt to exercise omnipotent control over his surroundings. His need to preserve a sense of control was so desperate that his otherwise outstanding reality contact temporarily lapsed when he felt his omnipotence challenged. Jay displayed ample indications of a pervasive identity disorder. He was confused about his gender identity and was prone to identify with women. No less striking was Jay's inability to experience himself as dependent, helpless or vulnerable, and his externalization of dependency and vulnerability. Hospital Treatment Jay was admitted to the latency-age unit of the Children's Hospital when he was 6 years old. A brief honeymoon period soon passed and Jay's controlling behavior became apparent. A new symptom also emerged: refusal to eat. Firm limits and clear consequences were set for manipulative and provocative behavior. At the same time, the staff discussed with Jay how difficult it was for him to trust and take anything that anyone had to offer to him, including food. Food supplements had to be added to his diet to augment his meager nutrition. Empathizing with his fears of "taking in" and the potential arousal of wishes for dependency and nurturance seemed to help Jay relax. Cautiously, he developed a tentative attachment to several staff members and to his teachers at the preschool. Several months following admission to the hospital, he began psychoanalysis. Jay's enormous vulnerability to separations became apparent during his first summer in the hospital. Because of his age, he was scheduled to move from the therapeutic preschool to the hospital's elementary school. Jay's behavior deteriorated markedly following this move. Temper tantrums in response to minimal frustration became the rule as Jay escalated his demands to subordinate everyone's wishes to his own. Disappointments led to furious fits of hitting, biting, spitting, headbanging, tearing his clothes or destroying furniture. At the same time his feminine mannerisms became more pronounced. He attempted to paint

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his nails and tied batteries to his shoes to pretend he was wearing high heels. He openly asked other boys to marry him and coyly conveyed his wishes to get pregnant and have a baby. The treatment team responded along two parallel tracks: (a) Firm containment of aggressive, impulsive, provocative or manipulative behavior (at times involving literally holding him down). Masculine behavior and identifications in his fantasy, play or interactions were actively encouraged while feminine play and behavior were discouraged. Cross-dressing and efforts to seduce other boys were limited. (b) Careful, empathic exploration of his fears of abandonment, hurt, and irreversible loss. An encouraging sign throughout this trying period was the genuineness and availability of Jay's feelings, in stark contrast to the "phony," manipulative quality previously demonstrated. A change in the quality of Jay's attachments became evident during the latter part of that year. He seemed more ready to trust people. He openly discussed his fears of abandonment and revealed the fantasy that being a girl allowed him to think that his mother had not died. In play and in his talks with staff, Jay furnished further evidence that his wish to be a girl was a desperate attempt to keep his mother alive. This fantasy defended him both from feeling helpless and deprived and from feeling that his voracious needs had destroyed mother. Gradually, Jay's upsets became less frequent and much less intense. His eating improved and he began to gain weight and grow up. Proudly he requested that the food supplement (which he called his "baby food") be discontinued. At the beginning of his second year in the hospital, a concerted effort was made to identify and support Jay's skills and competence and to provide him with the opportunity to develop real autonomy and individuation, in contrast to illusory self-sufficiency. Jay grew increasingly more interested in school and learning, even when he could not demand (as in the past) the teacher's undivided attention. With a good deal of encouragement, he began to enjoy his developing physical competence in sports and games. These were also Jay's first attempts to engage other children in play. A determined effort was made to more actively involve several male child-care workers in a variety of "father-son" activities which were designed to provide Jay with a male role model, to increase his pleasure and comfort in boyish activities, and to help him relate to a father-figure. Participation in a local Indian Guide Program, handicrafts, Boy Scouts, and tumbling were incorporated into his treatment plan. During Jay's second spring in the hospital, a new regression occurred following Jay's father's surgery for an inguinal hernia. Jay responded with overwhelm-

ing anxiety and an intensification of feminine behavior. As we explored his anxieties about his father's surgery, Jay was able to report his concern as to whether boys can become girls if they are subjected to a surgical procedure, which clearly indicated that his feminine wishes were also a counterphobic maneuver to deal with the threat of castration. An encouraging sign, however, was Jay's ability to quickly bounce back from his regression. He was able to talk about his anxieties and concerns and was able to return to a stable school and daily routine. But this vulnerability to regression continued during the next 2 years of Jay's treatment. The events which typically triggered regression to feminine behavior had the common theme of threats of abandonment and separation and/or bodily injury, as for example, surgery of the analyst or stepmother, or leaving the hospital school to attend public school. On those occasions, Jay's bossiness, manipulation, and intensified feminine mannerisms returned. These regressions, however, became rarer and briefer. Jay was not only more able to deal with stress and conflict but was also able to use support and understand the meaning of his distress. Thus, 2 years after admission Jay enrolled in public school. His relationships with other children were warm and appropriate, although he still shied away from competitive play and tended to gravitate toward girls. With adults he was more trustful, appropriate, capable of accepting limits and able to discuss his feelings and concerns. Another crisis emerged when the parents decided to separate. Jay became anxious and, again, strongly insisted on becoming a girl. Jay responded to increased staff support and brought to light a new aspect of his wish to be a woman: if he became a woman he could offer himself to father as a replacement of mother and thus prevent father's depression following the loss of his wife. This fantasy, which condensed aspects of negative oedipal wishes with earlier fears of loss of nurturance, was expressed in Jay's fantasies of marrying his father. The child's ability to withstand the stress without disruption of his school performance, interpersonal relations, and overall adjustment was considered a good indicator that the goals of hospital treatment had been accomplished. Thus, discharge was scheduled for the following June, after 3 years and 9 months of hospitalization. Psychoanalysis Jay began his psychoanalytic treatment by quickly developing a repetitive play theme centering on Cinderella, Snow White, and Sleeping Beauty. Enacting the fairy tale with dolls, he played the role of the heroine, the beautiful, yet tormented princess. Most

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of the time, the analyst (a woman) was left out of the play, reduced to the role of admiring audience, or expected to obey the stern commands of this most unrelenting and controlling "princess." Slowly, concerns about separation and loss crept into the sessions, particularly around the analyst's vacations. Jay initiated hide-and-seek games or pretended to be lost, challenging the analyst to search for him but never quite allowing her to "find" him. This game was perhaps Jay's cautious invitation to the analyst to share in his activities and his life. Soon Jay was busily staging storms and thundershowers which required him and the analyst to seek shelter under the desk. While Jay was in charge of ensuring that the many stuffed animals that he brought to the sessions were all accounted for and safe, he occasionally slipped and called the analyst "mom" or "dad." Increasingly Jay became preoccupied with food and nurturance. When he and the analyst took walks during the hours, Jay would gather fruit, which he then ate or shared with the analyst. As he fed himself and the analyst, he inquired about having babies and pretended that his stuffed animals were pregnant. The theme of the fairy tale princess, along with renewed interest in being a girl, emerged periodically and was typically associated with bossiness and insistence on being in control. Events involving real or symbolic threats of separation or abandonment triggered that particular association. The analyst carefully linked Jay's bossiness and wishes to be the Sleeping Beauty or Snow White with the boy's identification with his dead mother. If Snow White died but came back to life and Sleeping Beauty was not really dead but only sleeping, then perhaps mother could also be brought to life. He would not have to feel little nor helpless if he could become the mother-Sleeping Beauty, wanting to be waken up from her hundredyear sleep. The separation of Jay's parents, as well as the operations undergone by the boy's father and the analyst, brought to the fore a host of concerns about body integrity, death, and abandonment. To these events the boy responded with intensified feminine behavior. For example, he pretended to be Mary Poppins, coyly dancing with an umbrella. The analyst interpreted this playas the child's way to cope with anxiety, to retain his mother and analyst by becoming a woman like them, thus preventing any possible danger to his penis by denying he had one. The analyst's absence due to surgery provided an opportunity to work on issues of separation, abandonment, and anger. Jay's stuffed animals "felt" angry at having been abandoned and worried whether they could count on the analyst to get well and return.

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Expressing anger and concern about the separation seemed to free Jay to explore masculine pursuits and oedipal themes. The analyst, after all, not only got well and came back but was not injured, neither by the boy's neediness nor by his anger. Jay turned his attention in the sessions to competitive games, curiosity about the analyst's husband, and fantasies of sentencing the husband to death. Proudly he presented the analyst with a picture of himself, cockily attired in a Cub Scout uniform. Now, when he played the fairy tale theme, he often would wish to play the role of the prince. This venture into phallic and oedipal activities came to an abrupt halt when Jay's parents announced their decision to separate. He again became empty, hungry, controlling, and demanding. In the sessions, he demanded absolute control over the play and insisted on coaching the analyst as to what to do, acting as if the analyst was his puppet or narcissistic extension rather than his partner as she had been previously. The themes of the sessions revolved around the analyst playing a pregnant woman giving birth to twins, a boy and a girl. Jay would play the nurse or the obstetrician who would sadistically remove the babies from the mother, thwarting her efforts to hold them, care for them or take them home. The babies were sent for surgery (typically involving removal of genitals or amputation of a limb), were kidnapped by the nurse or were placed in some great danger. Jay instructed the analyst to ask for the babies and attempt to rescue them, but then arranged for her efforts to fail. The analyst interpreted Jay's concerns and anger at having been abandoned. In response to this interpretation, he requested the analyst to feed a baby doll with a toy bottle. When the analyst complied and held the baby doll, Jay pretended that the baby urinated on her. "Squirt, squirt, pee on you," yelled Jay in a challenging display of bravado that barely concealed his fear of retaliation. "It's okay to do that," responded the analyst, "babies are supposed to." With obvious relief and a mixture of glee and fury, Jay pretended to urinate, fart, and vomit on the analyst. When the analyst replied, "Baby is angry at mom for leaving him," Jay immediately shifted to become the baby himself and requested to be fed. When Jay bit the spoon full of cocoa powder offered by the analyst, she commented on the boy's emptiness and anger at being left. These remarks allowed Jay to relax and, perhaps for the first time, he was able to let someone nurture him and care for him. The nurturance Jay received in this and subsequent hours seemed to fuel a spurt of growth, mastery, and autonomy. This time, however, the boy's efforts appeared to be in the direction of genuine mastery, as

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opposed to omnipotent control. He brought his roller skates to the sessions and practiced skating diligently under the watchful eye of the analyst, impervious to falls. Sometimes he wished the analyst would hold his hand; other times he wanted her to walk alongside him without touching him; and occasionally he ventured on his own. Having mastered roller skating, Jay taught the analyst some folk dances he had learned in school and initiated a complex traffic control game. While skating, Jay instructed his stuffed animals about traffic safety and the many rules governing traffic. As soon as the stuffed animals "learned" the rules, they would "forget" them and mess up, or they would openly break the rules in defiance of all limits. For several months, these themes of separation-individuation and the anal material of defiance, compliance, and messing up were worked and reworked. The analyst's comments were focused on the boy's wishes to be in control of self and others and the difficulties he experienced in relinquishing some of that control and accepting the rules of adults. This material gave way to a fresh wave of oedipal themes. Jay invited the analyst, along with his stuffed animals (which he now called his "children"), to camp under a large pine tree. Jay took pains to ensure that the camping site was comfortable and safe for the family and instructed the analyst, whom he called "wife," to cook dinner for the "family." Jay stayed busy protecting the "house" from intruders, rescuing the "family" from fires and other dangers, and collecting food and supplies. Occasionally he slipped and called the analyst "mother" instead of "wife." During the following months Jay continued to consolidate his masculine identity. At times he reverted to the fairy tale princess theme or struggled with issues of separation, mastery or loss. His overall functioning in school, hospital unit, and family progressed to where plans were made for him to return home to the father at the end of the school term. During the final months of the analysis Jay worked on the termination. A new loss, of course, carried the risk of reviving previous traumas and reactivating old defenses. This time, however, Jay planned in advance how to prepare for the separation. He talked poignantly of past separations, reminisced of the years together with the analyst, and reviewed play themes of different stages of the analytic process. When dressing up to play Cinderella, he no longer looked feminine but rather like a boy being silly. Jay remarked that high heels were hard to walk in and the whole play "was boring." During the last hour Jay proposed a toast with pretend wine. "For a good therapy," toasted the boy.

Analyst and patient toasted each other and their respective families. The analyst toasted Jay's new caretakers while Jay toasted the "new patient" who would take his place. Finally, Jay asked the analyst to toast his future wife, a make-believe girl he appropriately had named "Hope."

Gender Identity Development Early object loss has long been recognized as a crucial factor in future psychopathology and/or character organization (Bonnard, 1961; Bowlby, 1961; Fleming and Altschul, 1963; A. Freud, 1943; Nagera, 1981; Spitz and Wolf, 1946). The impact of the loss of a parent for a young child is predicated not only on the traumatic nature of the event per se, but also on the loss of an essential provider and organizer of critical developmental opportunities and experiences. Hence, the final outcome of parental loss in early childhood depends to a large extent on the child's developmental stage when the loss occurs, the balance of developmental forces within the child at that moment, and the ability of the child and the environment to respond adaptively or pathologically to the developmental interference (Nagera, 1966) that the loss represents to the child. Thus it is relevant to turn our attention to the tasks of early development, particularly identity development, before examining how object loss disrupts the negotiation of those early developmental accomplishments. During the first 10-12 months of life children gradually put together in their minds the pieces of an image of mother as well as the pieces of their own image. The vague feeling of being one with mother recedes as children develop an increasingly more sophisticated sense of what is inside and what is outside, what belongs to them and what belongs to mother. Three basic factors provide the building blocks of the child's developing self-image: (a) the inexorable maturation of cognitive, motoric and perceptual abilities, pushing the child toward self-other differentiation; (b) the child's own inner feelings, states and sensations, including his activity level, adaptability, intensity of reaction, rhythms, sensitivities, thresholds of responsiveness, etc.; and (c) the child's experiences with the caretakers. This last aspect includes identifications of the child with his libidinal objects, and the impact of parental and cultural expectations, ideals and role prescriptions. Also related is Winnicott's (1965) concept of the mirroring function of the parents, that is, the parental capacity to notice, understand, and respond to the child according to the infant's own unique traits and sensitivities. In normal development, according to Winnicott's (1965) beautiful image, the baby looks at his mother's face and finds himself there. The fragmentary self-image resulting from matura-

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tional forces, inner sensations, and experiences with the caretakers slowly coalesce into a core sense of self. The child develops a growing capacity to experience himself as distinct and separate from mother, that is, he develops a mental self-representation that has boundaries and is differentiated from the representation of the object. The child's sense of self is bolstered by the maturational spurt in cognition, language, and upright locomotion of the practicing subphase (10-15 months) (Mahler et al., 1974). As Mahler and McDevitt (1982) state, "As the infant explores the animate and inanimate world with all sensory modalities, he learns more and more about himself and his relation to the outside world ... Encounters with inanimate objects in the environment help to firm up and delineate body self boundaries ... Now during the practicing subphase the infant acquires a practical sensorimotor and sensoriaffective schema of himself, which is sufficiently positive and autonomous to enable the practice of motor activities in the exploration of ever expanding environment at greater distances from the mother" (p. 842). In this perspective, gender identity is but one aspect of self-development. The developmental challenge for the child is the integration of different aspects of the self into a cohesive and stable representation, with continuity over time. The trend in psychoanalysis in recent years has been to attempt to integrate the above mentioned view, mainly derived from studies about the separation-individuation process (Mahler et al., 1974) and the early formation of self and object representation (Jacobson, 1964; Kernberg, 1976), with early psychoanalytic concepts of gender and sexual development, mostly centered around instinctual development and the oedipal phase. For Freud (1905) and the early psychoanalysts, boys and girls developed in much the same way until the onset of the phallic phase at about 3 years of a age. The first 3 years of life were thought of as a period of sexual undifferentiation. If anything, both sexes were seen as little boys, with the clitoris in the little girls substituting for the penis. Actual differentiation of masculine and feminine lines of sexual development was not thought to occur until the onset of the phallic stage and the discovery of the anatomical differences between the sexes. Sexual differentiation was deemed to reach a climax during the oedipal phase when the child experiences intense rivalry with the parent of the same sex for the affection of the parent of the opposite sex. The appropriate resolution of the oedipal complex was regarded as resulting in the child identifying with the parent of the same sex. Hence, resolution of the oedipal complex was believed, in the traditional psychoanalytic view, to be the foundation

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of the child's sexual identity, which subsequently was to undergo revision and consolidation during adolescence. Roiphe and Galenson's (1972, 1973, 1981) contributions best represent the efforts to integrate drivecentered concepts of sexual development with notions derived from studies of self-development, object relations, and separation-individuation. The major thrust of these authors' works highlights the importance of the preoedipal years in sexual identity development. According to Roiphe and Galenson, infants between the 15th and 24th month of life develop a distinct awareness of their genitals. So predictable is the occurrence of early genital awareness and so far reaching its influence on subsequent development, that Roiphe and Galenson designate this period as the early genital phase. This phase, state Roiphe and Galenson (1981) "runs concomitantly with the infant's increasing ability to differentiate between self and object; it occurs in both boys and girls and appears to be without any oedipal resonance. The underlying dynamic content of the early genital phase is normally concerned with establishing self and object representations, which now include the genital zone" (p, 36). Thus, according to these authors, the child's evolving self-representation expands between the 15th and the 24th month of life to incorporate a new and crucial component: the child's self-image now includes male and female genitals. Castration reactions, if they develop at this point, will not be associated with oedipal rivalry and fears of retaliation but with early experiences that "interfered with the developing sense of body intactness or with the mother-child relationship and thus produced an instability of self and object representations." We will return to this point later. A number of investigators, notably Green (1974, 1975, 1980), Money (1980), Money and Ehrhard (1972), and Stoller (1968, 1976), have confirmed some psychoanalytic notions while disagreeing with others. Several points of agreement among these investigators have emerged, including: 1. Sexual identity is a composite of developmental components: one's own experience of maleness or femaleness, the various behaviors and characteristics that publicly manifest one's gender identity, and one's erotic orientation or preference for sexual partners of one or the other sex. These components develop at different stages and may be affected differently by biological and psychosocial influences. 2. There are innate, nonlearned male-female differences. Sexual dimorphism regarding aggression, energy expenditure, exploratory behavior, space-form discrimination, and affiliative behavior is demonstrated in cross-culture surveys, is resistant to change,

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and is not randomly distributed, as would be required by pure cultural determination. 3. Fetal hormones play a role in the development of sexual identity, and this role is probably related to the induction of a sexual dimorphic prenatal central nervous system organization. This organization includes (but is not necessarily limited to) the "setting up" of the hypothalamus and related structures for the cyclic or tonic release of gonadotropins and for the mediation of female or male traits. 4. Gender identity is seen as one component of sexual identity. In Stoller's (1968, 1976) definition, gender identity is "that part of one's self-a set of convictions-concerned with masculinity and femininity. At its core, the earliest part to develop, is a taken-for-granted conviction that one is male or female-that is, one's assignment to the male and female sex was automatically and ultimately psychologically correct." 5. Core gender identity is first noticeable before age 1 and consolidates between 18 and 36 months. Once established, core gender identity is thereafter typically very resistive to change. The development of the core gender identity is a multidetermined process involving: (a) biological (embryological and endocrinological) factors, (b) genital anatomy (as a signal to the parents and as a source of internal sensations which confirm assignment), (c) sex assignment during rearing, and (d) "shaping" (the effects of conditioning and learning). The net result is considered, particularly by Stoller, as a kind of imprinting, operating through nonmental, nonconflictual processes. Psychic conflict, according to Stoller, may playa role in gender indentity development, but only later, perhaps during adolescence. It is this point we wish to address, given its obvious clinical implications. To isolate gender identity from other aspects of self-development and from the rich matrix of interpersonal relationships, conflicts and defenses, wishes and fantasies that constitute the template that shapes the self, significantly narrows the scope of our therapeutic interventions. Such limitation, of course, would be justified by the conviction that core gender identity disorders result from influences outside the child, untouched by life experiences or intensive treatment.

Object Loss, Self Development and Gender Identity Can Jay's zestful determination to survive enhance in some way our understanding of gender identity development? Jay experienced the loss of his primary caretaker when he was 3 months old. Spitz and Wolfe (1946), Bowlby (1961), and many others have carefully documented infants' responses to loss during the first

3 months of life. In Jay's case, the development of anaclitic depression or autistic withdrawal was perhaps avoided by the warm ministrations of his adoptive mother. At the same time, his history suggests that he was endowed with remarkable strengths and a generous supply of intelligence and sensitivity. Faced with an early loss he responded, like the children of "unusual sensitivities" described by Bergman and Escalona (1949), with precocious ego development and premature self-reliance. At the time of his adoption, he was a brash, ingratiating boy, with an uncanny knack of picking up interpersonal nuances. Rather than molding his body to accommodate to the symbiotic embrace of his mother, Jay held his body stiffly and vigorously insisted on having things his way. We can only speculate that the loss of his biological mother left this bright and resourceful child with a narcissistic vulnerability, a state of pain to which he responded with a tendency toward self-investment and self-reliance. The sudden death of Jay's adoptive mother brought him face to face for the second time with a devastating loss and the associated threat of ego rupture and disorganization. This loss occurred at a particularly sensitive moment in the child's development: at 13 months, the practicing subphase (Mahler et aI., 1974) of the separation-individuation process. Normally, children emerge from symbiosis (what Mahler calls "hatching") during the differentiation phase, between 6 and 12 months of age. As previously described, the relentless forces of maturation and development push children toward differentiation and distancing. For most children these developmental steps bring with them a dawning of just how little, helpless, and vulnerable they really are. Typically children respond to the momentous discovery of their smallness and separateness (between 8-12 and 15-18 months) by creating a wishful selfimage, an exuberant feeling of competence that undoes the anxieties of separation. "During these precious 6 to 8 months," says Mahler et al. (1974), "the world is the junior toddler's oyster. Libidinal cathexis shifts substantially into the service of the rapidly growing autonomous ego and its functions, and the child seems intoxicated with its peak!" (p. 71) The maturational burst in cognition, language, and autonomous locomotion of the practicing subphase provides the child with a powerful tool to handle the newly acquired sense of separateness and the loss of the symbiotic unity with mother. The child's narcissistic investment in his own functions, his own body, and the objectives of his expanding reality helps the child deny his own smallness and relative helplessness. Mahler et al. (1974) point out that the child is "exhilarated by his

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own abilities, continuously delighted with the discoveries he makes in his expanding world and quasienamored with the world and his own grandeur and omnipotence." Such elation is related, of course, to the proud exercise of new skills and competence. It is also linked to the "elated escape from fusion" as well as to the denial of the dangers and losses associated with undertaking that monumental step in develop ment, separation and autonomous functioning. The child's ultimate capacity to tolerate the awareness of separation from mother requires sufficient structuralization of his internal world. This structuralization encompasses the evolution of increasingly more effective adaptive and coping skills that guarantee intrapsychic autonomy. Of particular significance in this process is the child's capacity to set in his mind a mental representation of the mother that is libidinally invested even in mother's absence or at times of tension or frustration, that is, the achievement of object constancy. The loss of a maternal object as the child negotiates that developmental juncture has particular meaning and consequences. As Furman (1974) states, in his classic study of children's reactions to the loss of important objects, to the infant just beginning to achieve object constancy (like Jay) "the loss of the mother is a threat in terms of need fulfillment as well as a loss of essential narcissistic supplies, leading to enormous inner-need tensions and to gross narcissistic depletion" (p. 42). Furman found that children are developmentally inclined to deal with loss by identification, which frequently hinders the resolution of mourning. For a narcissistically vulnerable child such as Jay, the loss of his adoptive mother at the height of the practicing subphase brought a confluence of developmental and pathological trends. The developmental inclination toward identification was buttressed by Jay's previous losses and his need to preserve mother-by becoming like her-in a way that would protect him against future losses and helplessness. Furthermore, a grandmother who encouraged Jay to dress in the clothes of the mother, who provided him with dolls to play with , and who was in many ways bent on preserving in Jay the living memory of her deceased daughter, greatly fostered the child's identification with his mother. The normal narcissistic investment of the practicing subphase received tremendous reinforcement from Jay's heightened defensive need to protect himself from painful feelings of vulnerability, deprivation, helplessness, potential disorganization, and ego rupture. Moreover, Jay's omnipotence was enhanced by the special role he came to play in his grandmother's

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home. He was the apple of grandmother's eye, her only reason to live. Jay failed to experience the firm limit-setting and consistent demand to adhere to reality constraints that normally helps children relinquish omnipotence. His omnipotence was fueled by his identification with his lost mother, which increased his self-reliance and allowed him to avoid the need to depend on others. The child's emerging sense of self inevitably became entangled with the double push toward omnipotence and identification with the lost mother. The world owed him something and his caretakers behaved accordingly. Overvaluation and entitlement came from within and without. Assumption of a feminine role (to become like mother) became a consistent disposition to deal with threats of abandonment, loss, or deprivation. The normal narcissistic elation and self-sufficiency of the practicing subphase went well beyond the developmentally appropriate ego expansion before entering a "rapproachment" with the object world. Instead, it began to crystallize in a defensive organization based on omnipotence, self-reliance, need for control, and mistrust of others. Identification has long been described as a first step in the mourning process. As Anna Freud (1960) points out, it represents "the individual's effort to accept the fact in the external world (the loss of the cathected object) and to effect corresponding changes in the inner world (withdrawal of libido from the lost object) " (p. 58). In a positive sense, identification, as Furman (1974) remarks, "helps the ego to integrate past and future, to bridge the gap between the loss of one love object and the formation of a new object relationship" (p, 61). In Jay's case, the fateful identification with the lost mother was not simply the typical first step of an immature ego, struggling to master the massive trauma of the loss of a love object. Setting his mother inside of him did not provide Jay with a way station in the road to eventual decathexis and attachment to new objects, but with a replacement for the need of new maternal objects. The resulting fluidity of the child's gender identity, compounded by earlier losses (which presumably pro duced instability of self and object representations and interfered with his sense of body intactness), intensified the anxieties of the early genital phase described by Roiphe and Galenson (1972, 1973, 1981). Jay seemed to condense castration anxieties with previous anxieties about abandonment, deprivation, and body integrity. Evidence of greater ego stress and a breakdown in the child's capacity for control and modulation of sexuality and aggression became apparent when Jay was 2112 years old. Father had just remarried, an event

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that seriously strained the boy's adaptive capacities. Father's remarriage meant the loss of grandmother, a mother substitute whose loss seemed to reactivate previous losses. Along with grandmother Jay lost an environment that supported his omnipotence and identification with his mother. We may speculate that Jay's fears of abandonment were heightened by castration anxieties as he faced a new loss while negotiating the early genital phase. Thus he responded with an accentuation of maternal identification and a surge of negative oedipal wishes. His identification with mother seemed to acquire a new meaning: he became the competitor with father's new wife for father's love. We can only wonder whether the stepmother became the depository of the unexpressed rage at all the abandoning mothers of the past. Such formulation may shed light on the apparently paradoxical distress that Jay experienced years later when his father announced his divorce from the hated stepmother. Without the convenient displacement of the rage onto the stepmother Jay was left with the overwhelming burden of guilt that perhaps his own aggression had destroyed mother. At the time Jay was seen for treatment at age 6, he seemed well on his way to consolidating a narcissistic character organization with traits of omnipotence, manipulation, mistrust, control, interpersonal distancing, and exploitativeness. His gender identity confusion, likewise, while still fluctuating, seemed to be crystallizing into a feminine gender identity. Significantly, gender identity concerns emerged only indirectly in the psychoanalytic process, while most of the manifest work was on separation, loss, abandonment, and concerns about trust in parenting and caring figures. The unfolding of his treatment beautifully illustrates how the repeated expression and working through of rage related to loss of maternal objects allowed Jay to move forward developmentally into practicing, reapproachment, and later stages of object constancy. Phallic-competitive issues emerged clearly once he was assured that his aggression would not destroy (had not destroyed?) the maternal object. Reworking his early losses also allowed Jay to explore more typical oedipal themes and gradually give up his regressive retreat into an identification with the lost mother. This relinquishment was at first fragile and prone to break down in the face of potential separations or losses. Regression became short-lived as the treatment progressed. Close to the end, he was bored of dressing like a girl and preferred to play like a boy. Conclusion Obviously a swallow does not a spring make. One boy's history, however, does raise a number of clinical and theoretical issues. First, it suggests that gender

identity development is profoundly affected by the development of self and object relations, significant psychic events and conflicts, and the efforts of children to cope with such events and conflicts. Second, it suggests that a group of children who appear to have the characteristics of a core gender identity disorder may, on closer examintion in a psychoanalytic process, be shown to base their behavior on heightened narcissistic defenses against early maternal loss. Thus, a subgroup of gender identity disorders in childhood may be conceptualized. Third, it indicates that these children respond to intensive psychodynamic and developmentally based treatment. The main goal of the treatment was not to alter the child's gender role behavior (or even his gender identity) but to remove the blocks in the child's growth and reinstate him on the path of development. References BERGMAN, P. & ESCALONA, S. K. (1949), Unusual sensitivities in very young children. The Psychoanalytic Study of the Child, 3/ 4:333-352. BONNARD, A. (1961), Truancy and pilfering associated with bereavement. In: Adolescence, ed. S. Lorand & H. I. Schnner. New York: Hoeber, pp. 152-179. BOWLBY, J. (1961), Childhood mourning and its implications for psychiatry. Amer. J. Psychiat., 118:481-498. FLEMING, J. & ALTSCHUL, S. (1963), Activation or mourning and growth by psychoanalysis. Int. J. Psyclwanal., 44:419-431. FREUD, A. (1943), Infants Without Families. New York: International Universities Press. (1960), Discussion of Dr. John Bowlby's paper. The Psychoanalytic Study of the Child, 15:53-62. FREUD, S. (1893-1895), Studies on Hysteria. Standard Edition, 2:3305. London: Hogarth Press, 1975. (1900), The Interpretation of Dreams. Standard Edition, 4/ 5:1-621. London: Hogarth Press, 1973. (1905), Three Essays on Sexuality. Standard Edition, 7:130243. London: Hogarth Press, 1973. FURMAN, R. A. (1974), A Child's Parent Dies. New Haven: Yale University Press. GREEN, R. (1974), Sexual Identity Conflict in Children and Adults. New York: Basic Books. (1975), Human sexuality. In: American Handbook of Psychiatry, Vol. 6, ed. H. K. Brodie & D. Hamberg. New York: Basic Books, pp. 665-691. (1980), Sexual identity. In: New Directions in Childhood Psychopathology,ed. S. I. Harrison &J. F. McDermott, Jr. New York: International Universities Press, pp. 101-113. JACOBSON, E. (1964), The Self and the Object World. New York: International Universities Press. KERNBERG, O. F. (1976), Object Relations Theory and Clinical Psyclwanalysis. New York: Jason Aronson. MAHLER, M. S. & McDEVITT, J. B. (1982), Thoughts on the emergence of the sense of self, with particular emphasis on the body self. J. Amer. Psyclwanal. Assn., 30:827-848. PINE, F. & BERGMAN, A. (1974), The Psychological Birth of the Human Infant. New York: Basic Books. MONEY, J. (1980), Nativism versus culturalism in gender-identity differentiation. In: New Directions in Childhood Psychopathology, ed. S. I. Harrison & J. F. McDermott, Jr. New York: International Universities Press, pp. 89-100. & EHRHARDT, A. A. (1972), Man and Woman. Baltimore: Johns Hopkins University Press. NAGERA, H. (1966), Early Childhood Disturbances, the Infantile Neurosis, and the Adulthood Disturbances. New York: International Universities Press.

GENDER IDENTITY DISORDER AND OBJECT LOSS - - (1981), The Developmental Approach to Childhood Psychopathology. New York: Jason Aronson. ROIPHE, H. & GALENSON, E. (1972), Early genital activity and the castration complex. Psychoanal. Quart., 41:334-347. - - - - (1973), Object loss and early sexual development. Psychoanal. Quart., 42:73-90. - - - - (1981), Infantile Origins of Sexual Identity. New York: International Universities Press.

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SPITZ, R. A. & WOLF, K. M. (1946), Anaclitic depression. The Psychoanalytic Study of the Child, 2:313-342. STOLLER, R. J. (1968), Sex and Gender. New York: Science House. - - (1976), Sex and Gender, Vol. 2. New York: Jason Aronson. WINNICOTr, D. W. (1965), The Maturational Process and the Facilitating Environment. New York: International Universities Press.