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Publications: Book Reviews
Review of Identity, Gender and Sexuality: 150 Years After Freud

Title: Identity, Gender and Sexuality: 150 Years After Freud
Author: Fonagy, Peter Rainer Krause and Marianne Leuzinger-Bohleber
Publisher: Karnac
Reviewed By: Lora Heims Tessman, XXIX, no. 3, Summer 2009, pp. 58-61

How does changeable gender identity infuse the experience of self? The question animates literature and myth. For example, the spirited, cross-dressing, sex-changing “Orlando” (Woolf 1928) begins life as a young nobleman in the sixteenth century and moves through numerous historical and geographical worlds to become a modern woman writer in the 1920s. Orlando transcends both age and gender to have it all, not without his/her share of both joys and distress in each gendered position, within its culture, in which she finds him/herself. Orlando muses:


For it was this mixture in her of man and woman, one being uppermost and then the other, that often gave her conduct an unexpected turn . . . (p 189)


All the selves were different and she may have called upon any one of them. Perhaps, but what appeared certain . . . was that the one she needed most kept aloof, for she was, to hear her talk, changing her selves as quickly as she drove—there was a new one at every corner—as happens when, for some unaccountable reason, the conscious self, which is the uppermost, and has the power to desire, wishes to be nothing but one self. This is what some people call the true self, and it is, they say, compact of all the selves we have it in us to be; commanded and locked up by the Captain self, the Key self, which amalgamates and controls them all. Orlando was certainly seeking this self, as the reader can judge. (p  310)


The tale of Orlando was said to be Virginia Woolf’s tribute to her beloved friend Vita Sackville-West.

            The gist of Orlando’s narrative is based in the supposition that the subjective experience of gender, gives rise to diverse, unconventional, expressions of sexuality and fantasy life, linked to potential realization of a sense of “true self”. Now we are fortunate to have a multileveled treatise of this topic. Identity, Gender, and Sexuality – 150 Years after Freud is edited by Peter Fonagy, Rainer Krause and Marianne Leuzinger Bohleber, with a foreword by Claudio Laks Eizirick. It is comprised of a series of papers, each followed by a commentary and first presented at the Sixth Joseph Sandler Research Conference in March 2005 at University College London, which was devoted to the 100th anniversary of Freud’s “Three Essays on the Theory of Sexuality” and originally titled “Sexual Deviation: 100 years after Freud’s Three Essays on the Theory of Sexuality”. The change of title to that of the book is emblematic of the deepened and broadened views presented. Collectively the authors examine the warp and woof of those old assumptions that have historically linked identity, gender, sexual behavior and fantasy in psychoanalytic theory; and with fresh perspectives weave new frameworks for questions arising from research and clinical experience. The thoughtful commentaries add to the dialectic .The reader is stimulated to reconsider transvestism in children and adults, homosexuality, transsexuals with mismatches between behavioral and psychic identity, as well as the place of sexuality in psychoanalytic theory, including the sexual dimension as experienced by the analytic couple. The book attends to the question: Is sexuality disappearing from psychoanalytic discourse? The thinking of each author reassures us that it is not. In addition there are contributions that highlight the ways in which the past cultural context of derogation toward “sexual deviations” has been damaging to patients and theory, leading to biased frameworks of research. Excellent integrations of research models are proposed (and debated). It is difficult to summarize the chapters, not only because of their diversity, but also their richness.

            Peter Fonagy, in his introductory overview, provides a refreshing assessment of sexuality in terms of its being enjoyed. He proposes,


Within most modern psychoanalytic formulations the almost infinite variety of sexuality is accepted as normal and bounded only by the human imagination. However, like any human activity, sexuality is seen as serving multiple functions, and it is the service to which sexuality is put that indicates a fundamentally maladaptive character. Thus sexuality in the service of psychic survival, the substitution of a pseudo-relatedness for genuine intimacy, the disguising of hostility or hatred, or the erotization of aggression that could be triggered by intimacy—in these contexts modern psychoanalysis considers sexuality to be perverse. The key indicators are not the fantasy, nor the activity, but, rather, the compulsive, restrictive, and anxiety driven character. Normality and perversion is thus an inappropriate dimension that could and should be replaced by our understanding of the degree to which a particular type of sexual activity serves functions other than erotic pleasure. (p. 13)


After elucidating his understanding of how sexual arousal is internalized within the child-caretaker context, Fonagy acknowledges the natural role of arousal in psychoanalytic treatment:


In the analytic setting the analyst’s concern with the enigmatic is inevitably stimulating. I can think of only two categories of interpersonal stimulation where the exchange of subjectivities across a person’s physical boundaries is both mutually desired and legitimized: one is normal sexual excitement and the other is psychoanalysis. In particular it will be therapeutic relationships where the therapist shares some aspects of the subjective experience of the patient that are likely to elicit a response of sexual excitement from the patient. Similarly the therapist’s efforts to enliven the patient, to create a safe and secure intersubjective domain, will create and unusual opportunity fort him to experience his excitement through the patient’s subjectivity, to which he is so closely linked. Given the structural similarities of psychoanalytic therapy and nature of sexual excitement, what might surprise us is the relative infrequency with which sexual boundary violations occur rather than their disturbingly high prevalence. (p 19)


Fonagy regrets that references to sexuality that were key to Freud’s thinking have dwindled in psychoanalytic theory over the past decades. ”It is as if there is not space for sexuality within psychoanalysis . . . Psychosexuality is nowadays more frequently considered as disguising other, non-sexual self- and object related conflicts than the other way around.” Fonagy’s views reverse that trend.

Andre Haynal, in “Sexuality: A Conceptual and Historical Essay,” also comments on the dangers of neglecting the sexual dimension in psychoanalysis, but sees our recent emphasis on pregenital development and on narcissism as, theoretically, not opposed to considering sexuality as central. He points out that, “We find no exact correspondence between fantasies and behavior, as sexual excitement and behavior are based upon a complexity of genital and pregenital fantasies.” He adds an intriguing elaboration of the ways that “Sex is a powerful organizer of experience” (p. 28) in fantasy, in seduction in life, in analysis, and in particular cultural traditions, such as the couvades. A mix of drive and attachment theory informs his thinking. The commentary, by Sverre Varvin addresses the collision between object relations and drive theory in contemporary psychoanalysis, and the evolution in which “Object seeking was separated from the influence of the drives.” Varvin supports the need for several research approaches in psychoanalysis, including the qualitative approach, “which has the advantage of being able to follow the “fine threads of intimate dialogue.”

Marianne Leuzinger-Bohleber writes about “Psychodynamic and biographical roots of a transvestite development: Clinical and Extra-clinical Findings from a Psychoanalysis.” She demonstrates how “the three branches of clinical, conceptual and empirical research in psychoanalysis can supplement each other in a productive way” (p. 43). In the illustrative case, she studied the diary of a transvestite who had recorded each of his 624 analytic sessions” (p. 44), process notes from the analyst, and material from a follow up 24 years after the ending of treatment. A theory-guided, computer-supported content analysis of changes in the manifest dream content in the first 100 psychoanalytic sessions compared with the last 100 showed progressive improvement of cognitive-affective problem solving. But the clinical narrative was essential for understanding the biographic determinants for the unconscious embodiment of the meaning that “Transvestism, the unconscious fantasy to be an omnipotent man/woman, constitutes a narcissistic defense against the unbearable feelings of dependency on the (depressed) primary object.” (p. 47) Her developmental theory of embodiment in relation to contemporary models of memory and learning underlines her conclusion that “therapeutic changes do not occur after merely cognitive insights” since “embodied memories are constructed in the analytic relationship” and need to be remembered and worked through in the transference. (p. 71) In commentary, Linda Mayes notes that Leuzinger-Bohleber in addition to her contribution to research methodology, highlights “the theoretical shifts in understanding sexuality, and especially the role of early attachments and object relations in defining the range and depth of sexual orientation.” (p. 74)

            Richard Friedman addresses “The Issue of Homosexuality in Psychoanalysis,” reminding us of prejudiced psychoanalytic attitudes in the 1970s. He comments on his own pained experience: As recently as 1994, after co-authoring, an article on homosexuality in the New England Journal of Medicine, “I received a fair amount of – what can only be described as hate mail—from mental health professionals.” (p. 79) Friedman proposes, “the image associated with erotic arousal/excitement is part of an internally experienced erotic narrative “which is influenced by prenatal testosterone affecting sexual differentiation of the brain. He posits, interestingly, “For many, but not all men, once these fantasies are in place they tend to remain more or less constant for life. Women –far more diverse in many dimensions of their sexual experience and activity –are more likely to manifest plasticity with respect to their sexual fantasies and activity” (p 89). But exclusion by peers, domination, and rejection often hamper self-acceptance: “Boys on a gay developmental track are more likely than those on a heterosexual track to be bullied by other boys and men – sometimes including their fathers- because of what I will term here their gender-role temperaments. “ Friedman argues that such traumatizing experiences are more relevant for the homosexual than are the classical psychoanalytic theories about conflict, the negative Oedipus complex, regression and so. Commentator Anne-Marie Sandler makes the point that when homosexual patients come to analysis with the hope of becoming heterosexual, the important question for the psychoanalyst is “to discover whether the distress is linked to painful fantasies that they associate with homosexuality – for example shame, fear of rejection, and contempt for others, or whether homosexual relationships are used defensively by a person who has heterosexual wishes, fantasies and longings toward members of the opposite sex.” (p. 102)

             Susan Coates, in “ Developmental Research on Childhood Gender Identity Disorder” spans three realms of understanding the inner life of children obsessed with cross- gender behavior: developmental studies, illustrated by children’s pithy remarks about their perceptions of gender difference at various ages, conclusions from clinical experience based on careful differential diagnoses, and the beautifully detailed elaboration of treatment with one little boy, Colin, complete with a poignant series of his drawings in which he conveys “his sense of being colonized by his mother’s needs” in ways that made the development of a separate, autonomous self untenable. Sheila Spensley’s commentary agrees with Coate’s formulation of the psychodynamics as a defense against separation anxiety that involves the sense of “being the mother, rather than being with a mother” (p. 134). She adds a clinically important difference of meaning from more common varieties of separation anxiety: “The terror and panic involved is to be distinguished from separation anxiety in that it is not about the loss of the object, but about the loss of the sense of existence—hence the flight from reality to fantasy to preserve some illusion of selfhood” (p 135).

            Friedemann Pfafflin discusses “Research, Research Politics and Clinical Experience with Transsexual Patients”. He refutes the highly prejudiced, traditional conclusions about transsexuals. He notes that “In the psychoanalytic literature it is often maintained that the outcome of SRS is unfavorable and a mutilation; that the zeal of the patients never comes to an end; that many patients suicide postoperatively; and that the number of regrets is high” (p. 149). Marshalling “a meta-analysis of all follow-up studies after SRS published between 1961 and 1991, he finds the opposite: “Sex reassignment treatment is effective. Positive effects clearly outweigh undesirable effects.” Pfafflin notes that suicidality is much more frequent in preoperative transsexuals than after SRS, and he lists the factors promoting a good outcome. The chapter stands as a caution to us about those psychoanalytic formulations that are based on too small a number of cases and may reflect our unconscious countertransference to patients who evoke anxiety-laden identifications. In commentary, Peter Fonagy acknowledges that “We learn not just that our expectations of negative outcome from SRS appears largely unfounded, but also that we understand little about the causes of transsexualism and that working with half-baked ideas can sometimes do harm, not just little good”. (P.158)

            Rainer Krause theorizes about “Drive and Affect in Perverse Actions”, with particularly fresh illuminations about the uses of disgust in perverse actions, solutions and structures. He posits that disgust is “a propositional structure according to which a toxic object that is localized in the self is expelled out of the subject.” (p. 169) It keeps intimacy at bay, makes a “real erotic experience” which requires empathy for the other, impossible. In perverse solutions affective erotic misperceptions color body experience as well as social interactions. For example:


The phantasm of having a child’s penis can be observed in most cases, especially in paedophiles . . . The reality misperception goes beyond the fetish, however. In a study with sexual offenders who abused children they were in charge of, the most consistent event was that the men were convinced that children would have wanted and provoked this kind of “love.” (p.172)


In treatment “the patients’ transferences oscillate between the fear of a complete rejection, and the apprehension they could include the therapist in their eroticized phantoms.”(p.173) Suggestions for helping the therapy survive the patient’s compelled enactment of being disgusting are presented. Commentator Rudi Vermote writes appreciatively of the ways that Krause’s model can be utilized in psychoanalytically informed hospital treatment:


We can understand the patient’s problem as a combination of a motivational system of attachment and of seduction with the antagonistic affects of disgust and contempt, affects he communicates and evokes strongly in non-verbal ways. This understanding makes the peculiar transference-countertransference interactions with this patient more bearable. Staff members can recognize his provocative behavior as a need for closeness despite evoking affects of disgust and even fear. (p. 179)


In the tour-de-force “Conclusion: Future Clinical, Conceptual, Empirical and Interdisciplinary Research on Sexuality and Psychoanalysis,“ Marianne Leuzinger-Bohleber deftly crystallizes the issues evoked in each chapter. She ventures:


Often empirical researchers claim that clinicians—in contrast to (empirical) researchers—need to feel secure in the clinical situation, thus searching for beliefs, even ideologies, and avoiding a self-critical attitude full of doubts. I personally think that this is not true. On the contrary: “good clinicians” share with “good researchers” an attitude of “not knowing,” of curiosity, self-critique, and a “constant searching for truth” (as opposed to certainty) —and thus an attitude of humility… (p.188)


Well said!

            Freud’s own, complex stances toward homosexuality, as home base from which the authors journey, are not elaborated in the book (with the exception of his letter to the mother of a homosexual). Freud’s attitude was tolerant for his time, in contrast to prevailing psychiatric theory, which explained homosexuality as “degeneracy” (e.g., Kraft-Ebbings treatise on homosexuality). Freud considered it not to be illness, but an “arrest of sexual development,” a passing phase that is normally outgrown. In 1930, he called for the decriminalization of homosexual acts in Germany and Austria. In The Three Essays, (Freud 1905) Freud argues against degeneration as a cause of homosexuality because it is found in people (1 “who exhibit no other serious deviations from the normal” and (2 “whose efficiency is unimpaired, and who are indeed distinguished by specially high intellectual development and ethical culture.” Freud’s best known communication about homosexuality appears in his 1935 Letter to an American Mother (Freud 1935/1960): “Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness; we consider it to be a variation of the sexual function, produced by a certain arrest of sexual development. “ A complication of Freud’s view of homosexuality as “arrest” is that, for some decades, it was used to support the theories of those whose goal for treatment was to have the homosexual “convert” to heterosexual “maturity.” None of the contributors to this volume would be in accord with such a pre-conceived goal.

            Sexuality sculpts our individual visions of happiness. Freud (1915) held that “All intense affective processes, including even terrifying ones, trench upon sexuality,” and that “sexual love is undoubtedly one of the chief things in life, and the union of mental and bodily satisfaction in the enjoyment of love is one of its culminating peaks . . . all the world knows this and conducts its life accordingly; science alone is too delicate to admit it.” (p. 203) But sexuality can also endanger the self. As an Updike character in Couples (McEwan 2009) reflects : ” Nature dangles sex to keep us walking toward the cliff”. The authors of  Identity, Gender and Sexuality: 150 Years after Freud revive the central importance of sexuality for psychoanalytic theory, and are not “too delicate to admit” its varied fates to scientifically empirical and political scrutiny. Their revisions, with eyes open to what has been learned, are wonderfully jarring additions to what we thought we knew.



Freud, S. (1905). Three essays on the theory of sexuality. In J. Strachey (ed. and trans.), The standard edition of the complete psychological works of Sigmund Freud, 7: 123-243 London, Hogarth Press, 1958 (Original work published in 1905).1958..

Freud, S. (1915). Observations on transference love: (Further recommendations on the technique of psycho-analysis). In J. Strachey (ed. and trans.), The standard edition of the complete psychological works of Sigmund Freud London, Hogarth Press 1958. 12: 159-171.

Freud, S. (1935). Anonymous (Letter to an American mother) The letters of Sigmund Freud. E. L. Freud. New York, Basic Books, 1935; pp. 423-424.

McEwan, I. (2009). "On John Updike" The New York review of books: 3-12-2009 4-7.

Woolf, V. (1928). Orlando. New York, London, Harvest Book, Harcourt Inc.


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