Psychoanalytic Perspectives

ISSN: 1551-806X (Print) 2163-6958 (Online) Journal homepage: https://www.tandfonline.com/loi/uppe20

The Rending of the Skin-Ego and Second Skin: The

Formation of Paraphilias as Attempts to Contain,
Repair, and Transform the Damaged Self

Leslie M. Lothstein

To cite this article: Leslie M. Lothstein (2019) The Rending of the Skin-Ego and Second Skin:
The Formation of Paraphilias as Attempts to Contain, Repair, and Transform the Damaged Self,
Psychoanalytic Perspectives, 16:1, 48-69, DOI: 10.1080/1551806X.2018.1554957

To link to this article: https://doi.org/10.1080/1551806X.2018.1554957

Published online: 24 Jan 2019.

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Psychoanalytic Perspectives, 16: 48–69
Copyright © 2019 National Institute for the Psychotherapies
ISSN: 1551-806X (print) / 2163-6958 (online)
DOI: https://doi.org/10.1080/1551806X.2018.1554957

THE RENDING OF THE SKIN-EGO AND SECOND SKIN: THE FORMATION

OF PARAPHILIAS AS ATTEMPTS TO CONTAIN, REPAIR, AND
TRANSFORM THE DAMAGED SELF

LESLIE M. LOTHSTEIN, PhD, ABPP

Paraphilias are complex emotional expressions of embodied, prelinguistic memory associated with
traumatic ruptures in the child’s sensory skin-ego (the earliest mind projected onto the skin) that form
the structural basis for the paraphilia. The skin-ego ruptures function as lifelong vulnerabilities to
structural deficit in self-development and may preclude the development of a cohesive self (as ancillary
to an adult mind), derail desire and sexuality, and lead to paraphilias (delusional second-skins that
conceal rendings in the child’s sensory skin-ego and impair the formation of a neurotypical adult-
emotional mind). Moreover, paraphilias fail to protect the self against further decompensation (e.g., in
symbol formation and abstract reasoning), making long-term psychotherapy a necessity.
Treatment for paraphilias must initially focus on the structural failures in skin-ego and the evolving
separation anxiety and impaired self-cohesion. The treatment focus can then shift to the content of the
paraphilia, which reflects the influence of familial, cultural, spiritual, and personal meanings associated
with the traumatic ruptures that are being enacted as a form of a narcissistic behavioral disorder. Three
cases are presented (two men and one women) to demonstrate the relationship between the rendings of the
skin-ego, disorders of the self and mind, and the need for long-term treatment of the paraphilias.

Keywords: attachment problems, fetish, perversion, self development, skin-ego.

The past is never dead. It’s not even past.

— William Faulkner (1951), Requiem for a Nun
Nothing can be sole or whole/That has not been rent.
— W. B. Yeats (1933), “Crazy Jane Talks with the Bishop”

Introduction: Psychoanalytic Perspectives on Skin

The concept of skin in psychoanalysis is now well established as a core concept in

the development and origins of the embodied self (Ulnik, 2007). The pioneering
work of Bick (1968, 1986, 2002), Anzieu (1989, 1990, 1999), and Anzieu and Tarrab
(1990) is central to the psychoanalytic interest in skin and its role in psychic
development. The relation of culture to skin ego and the various ways culture
influences the skin ego in psychic development has been the focus of many authors

Address correspondence to Leslie M. Lothstein, PhD, ABPP, 68 South Main Street, West Hartford, CT 06107.
E-mail: leslielothstein@gmail.com

48
 The Rending of the Skin-Ego and Second Skin 49

(Fannon,1952; Tyler, 2001; Benthian, 2002; Jablonski, 2006; LaFrance, 2009; Cheng,
2010; Raufman & Yagael, 2011; Cavanaugh, Faller, & Hurst, 2013; Thompson, 2013;
Raufman & Weinberg, 2016). Anzieu (1989) introduced the concept of the skin-ego
and wrote extensively on the topic, focusing on the skin-ego as primarily an
embodied mind emerging out of the sensory experience, and only secondarily
later in life as self, mind, psyche or ego-mentalizing subjective agencies.
Connor (2004) noted that for Anzieu, “the (earliest form of the child’s) ego is
the projection of the psyche on the surface of the body” (p. 49). The emerging skin-
ego first arises as a “mental image of which the ego of the child makes use during the
early phases of development to represent itself as an ego containing psychical
contents, on the basis of the experience of the surface of the body” (p. 49).
Anzieu (1989) grappled with problem of mind–body dualism, and his solution
was to develop a way of thinking of the soma and psychic as one and interchange-
able. For example, LaFrance (2013) noted that for Anzieu, “every property of the
mind can be reduced to the properties of the body” (p. 27). As many functions of
the body are expressed through the skin, the “body’s surface—its skin—is seen as
a crucial constituent of the mind’s structures and functions” (LaFrance, 2013,
p. 16), eventually becoming a fundamental part of embodied subjectivity and
psychical corporality. For Anzieu, the body-ego is a skin-ego that has eight functions
(all of which are involved in the development of a paraphilia): containment,
protection, inscription, maintenance, individuation, intersensoriality, sexualization,
and recharging (Anzieu, 1989).
Bick (1968, 1986, 2002) coined the term “second skin” to refer to the
establishment of a phantasied protective body buffer zone to manage overstimu-
lation and prevent the flooding of the body with unmanageable anxieties, leading
to the collapse and disintegration of the primary skin barrier of the self.
The second skin is a shield and then a container (an envelope). Third and fourth
skins develop as the adult needs additional protective barriers (North, 2013).
The concept of psychic envelopes (Houzel, 1996; LaFrance, 2013; Mellier,
2014) was introduced to expand the narrative of the mind–body connection
(Prosser, 1998; Pile, 2009; Tustin,1990; Vivona, 2009). Feldman (2004) noted
that the “concept of the psychic skin as an early form of psychological boundary”
became an important concept for psychoanalysts, and that “the development of
the psychic skin, or psychological container, is necessary for the imaginal pro-
cesses to function for the purpose of psychological growth and development”
(p. 1). According to LaFrance (2013), “Psychic envelopes are sensory experiences
that have been transposed from the somatic plane onto the psychic plane; once
transposed, they are structured like, and function as, the envelopes of skins, of
the psyche” (p. 31). Mellier (2014) noted that there are two sheets of the skin-ego
that become envelopes: “an external face which receives inscriptions but does not
store them, which resists destruction but remains rigid, [and] a malleable inner
face, which stores the inscriptions and meanings” (p. 3). The psychic envelope is
50 Leslie M. Lothstein, PhD, ABPP

formed from multiple layers of sensation (intersensoriality). Stern (1985) distin-

guished between different types of psychic envelopes according to “various types
of operations that involve intersubjectivity, maturation and the corporeity of the
baby” (p. 7). He expanded the concept of psychic envelope to include envelopes
based on sensory input, emotion, state of mind, and action. From
a developmental standpoint, failure in maternal care during early childhood
results in failure of psychic envelopes to provide both functional and adaptive
protection and meaning to self-structure (Elmendorf, 2007; LaFrance, 2013;
Lemma, 2010, 2015; Kohut, 1977; Kohut & Wolf, 1978).

Skin and Skin-Ego: The Development of Paraphilia

The past of the child is never dead and is alive prelinguistically as body-memory in
the adult’s psyche (Freiberg, Adelson, & Shapiro, 1975; Gallagher, 2005; Karr-Morse
& Wiley, 2013; Coates, 2016; Harris, Kalb, & Klebanoff, 2016). From this perspective,
all of the aspects of one’s skin-ego provide a cognitive-affective map to understand
the role of paraphilias in adolescence through adult development. In this paper
I want to expand our thinking about the origins and psychodynamics of paraphilias,
or what has in the past been labeled as perversion (Khan, 1979; Stoller, 1975). The
process of developing a healthy skin-ego can sometimes go awry due to childhood
trauma, resulting in a weakened and unprotected ego structure that is emotionally
flooded, and creating vulnerability for ruptures in the skin-ego as well as later
ruptures in psyche and thinking, leading to the adult expression of a paraphilia.
Paraphilias are rooted in early childhood trauma (Schwartz, 2008; Schwartz
and Southern, 1999) at the earliest stages of the emergence of a sensory-mind (the
skin-ego). The rupture in skin-ego development creates a specific type of vulner-
ability in human relatedness associated with separation anxiety (sometimes at the
level of annihilation anxiety), and leads to the form and repeated enactments of the
paraphilia with no hope for a solution (Stoller, 1975, 1991; Lothstein, 1988, 1997;
Kilby, 2001; Turp, 2007; Katehakis, 2016). In most cases of early childhood sexual
abuse in which the child’s body and ego are vandalized (Money, 1986), problems in
symbol formation, mentalization, and body-self cohesion are the outcome (Klein,
1930; Segal, 1965). Depending on the level of sadism and cruelty involved in the
vandalization of the child’s body, one sees ego defects in the executive functions,
secondary to failure in symbolization and in some cases psychosis (Stoller, 1991).
Because the trauma was registered prelinguistically, it is experienced as sensations
and embodied memory, and therefore is difficult to access verbally.
Fonagy and his colleagues (Fonagy, 1999; Fonagy, Gergelov, Jurist, & Target,
2002), as well as Schore (2003a, 2003b), have written extensively about how the
failure of parents to serve as protective shields (i.e., surrogate primary skin-egos)
for the child may lead to defects in the child’s regulatory system. Many children
in a state of emotional dysregulation cannot calm themselves and may seek
 The Rending of the Skin-Ego and Second Skin 51

alternative neuropathways of self-containment that may be expressed as paraphi-

lias in later development. Essentially, failures in skin-ego containment may be
expressed as neurobiological vulnerabilities of a traumatized body-self, subse-
quently affecting the child’s development of healthy attachments and future
intimacy and love relationships. Early failures in containment may leave the
child traumatized throughout her course of development and are then refer-
enced psychosexually during periods of great stress and turmoil. In the adult’s
life, a paraphilia may provide some relief from sexual desire (Coates, 2016;
Coates & Moor, 1997; Fraiberg, Adelson, & Shapiro, 1975; van der Kolk, 1994).
In this vein, the later adult expression of hyper- and compulsive sexuality may be
viewed as an attempt at reparative enactment to enliven a dead self and mend the
failed connection between a confused mind and an anxious body (Pines, 1980).
For traumatically overstimulated children (Coates & Moore, 1997; Fonagy,
1999; Fonagy, Gergelov, Jurist & Target, 2002; Schore, 2003a,b; Katehakis, 2016),
the earliest formations of self-representations are associated with a perpetual state
of high arousal and a fear of mind–body disintegration or incohesion. This state
has a cascading effect on the child’s evolving self, gendered body development,
and capacity for intimacy and love relationships (which is why gender dysphoria is
often associated with paraphilias). During periods of extreme stress, the self may
seek out illusory (Jimenez & Moguillansky, 2011) solutions to cohesion in the
form of a paraphilia. The paraphilia provides an illusory “cure” to depressive
despair by allaying separation anxiety and substituting sexual excitement and
hyperarousal for the painful affects associated with separation trauma, annihila-
tion anxiety, and lack of self-cohesion and incohesion between self and others.
Elsewhere (Lothstein, 1997, 1988, 1995), I have suggested that paraphilias
provide an illusory substitute for defects in symbolic function. Paraphilia protects
a damaged self from experiencing overwhelming annihilation anxiety through
the provision of temporary comfort and security experienced in the actions of the
paraphilia—a second skin solution. In paraphilia, the adult turns to erotic and
excited images or manic sexual enactments as a basis for feeling alive, contained
and secure. However, it is only a partial or illusionary solution to a complex
development trauma and is enacted over and over again with no real solution in
sight. In this respect, paraphilias create a unique form of psychological armoring
(third and fourth skins to manage desire) that are extensions of prelinguistic
defensive operations. However, a brief reprieve is swiftly usurped by the after-
effects of ejaculation or orgasm that bring a return to one’s depressive despair
and self-loathing once the transient effects of the endorphins dissipate. The
paraphilia is incessant in its control over the self’s lack of mindfulness.
Paraphilia enactments reflect a vicious cycle that causes great harm to
a person’s intimacy and sexual development. The developmental pathway to
a paraphilia typically begins with skin-excitement (the emergent sensory mind)
and ends in recriminations and shame as the rational-cognitive mind converts
52 Leslie M. Lothstein, PhD, ABPP

skin excitement to words. In terms of partial solutions to problems with contain-

ment and anxiety, some body piercings and other attacks on the body (that are
not merely decorative or part of a social expression of identity) may also serve
as second skins that are defensive processes to ward off feelings of deadness and
emptiness secondary to a lack of self-cohesion.
Kohut (1977) listed the paraphilias as part of the narcissistic behavior dis-
orders associated with failures in childhood containment and development asso-
ciated with the child’s impaired exhibitionistic needs secondary to a failing in
childhood mirroring experiences (a necessary link for healthy self-esteem and to
mitigate excessive anxiety) and later on a failure in idealizing functions. For some
children psychotic fantasies, delusional reveries, and hallucinations may be epi-
phenomena of the emergent paraphilia.
In the course of development, the child’s body may be vandalized physically
and/or emotionally by sexual abuse or intrusion so that the early skin-ego is rent and
affective regulation is impaired, leaving the child vulnerable to the linking of dysre-
gulated affect to desire and forming the groundwork for the later paraphilia. With
the onset of puberty, the vulnerable self may find an illusory solution to separation
anxiety and despair through masturbation and the excitement (a purely sensory
experience) and calming effect such a process has on the damaged self. More recent
scientific studies (Hiller, 2004) provide a neurobiological explanation for this
sequence as the brain moves from excitement (dopamine) to calming (endorphins)
and attachment versus excitement (oxytocin and vasopressin; cf. Fisher, 2005).

Relational Analysis and Paraphilia

Paraphilia is unique to each person, like a fingerprint. The content of

a paraphilia has its roots in the family, culture, and system of the child’s lived
experience, subjectivity and intersubjectivity (Goldberg, 1995, 1999, 2000). The
paraphilia is a sign that genuine relational connection with others is not possible
and must be manipulated, contrived and deceitful. Because the nascent self is not
“a closed-in biological system but it is from the first open in relation to an
environmental field and has the potential to come alive to self and others”
(Diamond, 2013, p. 177), there is always the hope that a new object relationship
will be reparative of the original rending and the evolving separation/individua-
tion failures and that the self can change and grow into a cohesive and coherent
self-system. This process becomes the focus of treatment as manifested in
a relational analysis in which the analyst becomes a projection for the perversion.
As newer conceptualizations of the neurobiology of sex and gender are
explored in treatment (e.g., gendered skin; cf. Lothstein, 1988) and fourth-layered
(self-object) skins evolve, distress is perceived by the damaged self and integration
sought through the embodiment of new forms of relational attachments. As treat-
ment progresses, the analysts’ second skin provides a protective barrier for repair to
 The Rending of the Skin-Ego and Second Skin 53

occur in the patient. This relational process has both psychological and neurobiolo-
gical meaning for both parties, explained by Kohut (1977, 1979) and Kohut and
Wolf (1978) as the embodiment of the self-object transference in which new self-
objects are provided and sought after by the patient (and perhaps the analyst). In all
analytic work with the paraphilias, introspective empathy by the analyst has its
dangers for the analyst, as the relationally based transference comes alive in the
treatment for both parties (analyst and patient), and boundaries and skin-ego
rendings are bidirectionally experienced. In the Menninger study (Kernberg et al.,
1972) on the psychoanalysis of primitively disturbed borderline (psychotic) patients,
it was shown that without an understanding of a relationally bound transference, the
analyst is subject to experiencing serious symptomatic distress and regression.
All paraphilias have a structural and content basis. The structural part involves
vulnerabilities in the ego related to rending in the skin-ego and evolving separation
anxiety themes that dominate the treatment. The content is overdetermined by
family dynamics and conflicts. In all paraphilias, family dynamics are relationally
embodied in the content of a person’s perverse enacted fantasies, many of which
are violent, projected from the child’s skin-ego onto the evolving adult psyche. In
the vast majority of paraphilic cases, primary shame, self-loathing and hatred, and
disturbing nonverbal memories are apparent. For example, the return to the
intense affective scenario of the original rupture of the skin-ego may be experienced
as vertigo, extreme anxiety, and fear, along with skin diseases. In adolescence,
symptomatic cutting of the skin surface concretizes remnants of childhood prever-
bal anxieties about intactness and relatedness of the primary container, the skin.
There are also specific gender (Kaplan, 1991) and cultural (Bhugra, Popelyuk, &
McMullen, 2010) differences in primary and secondary skins regarding paraphilia.

Clinical Illustrations

Modern man has an epidermis rather than a soul. — Joyce (1977, p. 21)

Case 1: Jacqui—an Adoption Gone Wrong: Psychosis and Body-Self Confusion

Manic sex isn’t really intercourse. It’s discourse, just another way to ease the insatiable need for
contact and communication. In place of words, I simply spoke with my skin. — Cheney (2008, p. 7)

Jacqui has been in treatment for 25 years. She has a history of multiple
psychiatric hospitalizations, day hospital treatment, and problems with alcohol
and drugs. She has been treated psychiatrically with antipsychotic and anti-
impulsive medications for 23 years. She is highly educated but had to drop out
of a PhD program because of her mental illness. Jacqui entered treatment to
learn more about her desire to become a male. She said, “I have a male body and
male skin,” and she felt like a male trapped in a female’s body.
54 Leslie M. Lothstein, PhD, ABPP

Jacqui experienced early trauma related to her adoption, failure to make

a secure attachment to the adoptive mother, and her father’s vandalization of her
gender by treating her as his son. As a teenager, she was raped multiple times and
became withdrawn and paranoid. She was also diagnosed as psychotic and having
a borderline personality organization. As an adult she married briefly, got pregnant,
and then divorced, and for several years she was not able to raise her daughter, who
was cared for by Jacqui’s adoptive parents (with whom she visited on weekends).
In response to her intense anxiety and micropsychotic paranoid states and
dissociation, Jacqui formed many “second skins” to protect her body and inner
self from being further ravaged. She wore bulky clothes, abused alcohol, and cut
her body and tattooed the places on her skin where she was sexually victimized,
drawing stars on body parts that were desecrated. For years, Jacqui wore combat
boots to bed and when showering. She rarely took off her boots. At night she
fought off sleep for fear of being attacked while sleeping. In her fantasy, sleeping
was equated with losing control and being vulnerable to sexual assault or murder.
She slept on a wooden floor and locked herself in her small bedroom, wearing
her boots to bed in case she had to protect herself from an imaginary intruder. As
part of her protective armoring, her boots functioned as a second skin. Her
unisex clothing also functioned as a second skin, a kind of antiexhibitionistic
armor, allowing her to be alive but concealed, hidden and protected. She
experienced profound disgust at the thought of wearing anything feminine. But
she was also attracted to very feminine and sexy women. She pretended to be
invulnerable and held back tears, believing they made her more vulnerable to
sexual assault. Her primary defenses were dissociation, isolation of affect, projec-
tive identification, and splitting. During therapy, she externalized her sexual and
aggressive impulses and felt vulnerable and feared loss of control.
For many years, Jacqui came into the therapy hour and stared at me, some-
times lovingly, sometimes with distain, and often with suspicion and hate.
Frequently, she asked me to talk in order to hear another person’s voice and
know that she was not alone. I experienced her silences as deadly and demanding,
and she got under my skin. When she heard my voice, she responded by becoming
sleepy and comforted, as if I were reading her a bedtime story. I had to be very
careful, however, with the words I used, as her early childhood was filled with verbal
recriminations from mother and hostile demands by father, leaving her trying to
make meaning out of my content while hearing the structure of my words as
a lullaby. In this maternal-infant scenario we were able to connect to each other
and therapy became a safe place for her to be, even if she couldn’t find the exact
words she frantically sought to describe her chaotic internal experiences.
As she shared her traumatic childhood, Jacqui also described a hypermanic
sex life that led to eight abortions and three miscarriages. A few of her pregnan-
cies were due to gang rapes by peers and sex with her high school history teacher
and a pastor at her church. Three of her pregnancies, two of which she
 The Rending of the Skin-Ego and Second Skin 55

terminated, were with her husband. She stated that the abortions were retalia-
tions for being abandoned by her birth mother and given up for adoption. She
wrote the following about herself:

I thought I was as bad as my real mother because I believed she had sex before she got
married and that is how she got pregnant and why she had to give me away when I was born.
I had inherited her bad blood. I had bad blood. I was bad, just like her. This is the beginning
of my learning from experience. It was not that I learned people would hurt me and use me,
it was that I learned I was a horrible person that had no value because I had somehow allowed
this to happen because I had alcohol. That was not the first time I drank, though. I had been
drinking for a while before that day. I would drink my father’s alcohol before school and
whenever I could. I have hated myself for so long and so deeply. I hate myself for being so
bad and for having bad blood and for doing bad things and for drinking and for sex and for
in some way allowing it to happen. I have thought in my life that there was something bad
that happened prior to this at age 14. I do not love me. I hate me. I do not treat my body with
care or kindness. I say I hate you to me whenever I start to masturbate. I hate myself, truly.
I hate me. I hurt me or am not nice to myself. This, I believe, is due to my bad behavior
because of bad blood like my real mother. As I write this, I am starting to feel a sensation
between my legs, almost a heat and some excitement. I do not want this to be true, but it is.
I feel I should stop writing, yet I think I am making sense of this life and what has happened.

At one point in treatment, Jacqui talked about her “imaginary” penis and
had two narratives to share: (a) that as a child her real penis was amputated, and
(b) that she had an internal penis inside of her (a psychotic fantasy she devel-
oped about a hernia under her abdominal skin). She believed that if she had
been born male, she would not have been abandoned or raped. In our work,
Jacqui came to understand and verbalize that what she perceived to have been
both taken away from her and inside of her (the imaginary penis) was her birth
mother.
During the early phase of treatment, she entered a paraphilic relationship
with a bisexual, bigendered man who was sadomasochistic. During sex, she
regressed and sobbed. Afterward, she cut herself and drew red stars on specific
body parts where she felt desecrated, and occasionally mutilated her genitals. In
between sessions, she wrote lengthy narratives about things brought up in her
therapy sessions that she could not put into words. Many of her writings focused
on her attacks on her skin and her cutting behavior. In this way she was able to
mentalize and experience what was, until then, only embodied and somatically
represented.
Underneath Jacqui’s rough facade and violent handling of her skin lived
a girl who was yearning for a nurturing, gentle maternal care. During treatment,
she experienced embodied memories about being breast-fed by her birth mother
and a desire to be breast-fed by her therapist, in which the penis became a breast
substitute. Putting these thoughts into words was very difficult, and at times, she
was both surprised and traumatized by her insights.
56 Leslie M. Lothstein, PhD, ABPP

In the tenth year of treatment, Jacqui expressed a desire to meet her birth
mother and wrote to the adoptive agency. She was told that the birth mother was
also looking for her and had registered with the agency to contact her daughter.
In the interim of her search, Jacqui learned that her birth mother had died; there
would be no reunion. She lost hope and had fantasies that she had killed her
mother. To undo the “murder,” she crafted a “shame doll” and carried the doll
her with her as a testimony of her shame, concretizing what she could not hold
symbolically in her mind. She also pushed her shame outside herself, projecting it
onto the doll and then identifying with the shamed doll. The shamed doll was
genderless and expressive. This process helped her talk more freely and write
more extensively and coherently about her shame. At this point in treatment,
Jacqui developed an olfactory hallucination of smelling her mother’s body and
believed the odors were from the dead birth mother while breastfeeding. During
this period, Jacqui was living with a man, and, to combat her disorganization and
despair, related to him as her male second-skin: a quasi-protector, a shield,
defending her from her dissociation and regulating her drinking, hypersexuality,
bisexual fantasies, and rage. Essentially, he functioned as her container and
carried out maternal functions that kept her alive and regulated when they
went to bars, casinos, and strip shows.
During one summer, Jacqui developed a fetish for my arm hair. She could
not take her eyes off my arms and was overwhelmed and confused by her desire
for me (as a part-object). She then moved from a focus on arm hair to my feet
and shoes, and became upset if I wore a pair of shoes that she hated. Being with
her felt creepy. I existed only as a figment of her imagination, not a whole person
but a set of appendages. I explored with her the meaning of her desires while
exploring her mindfulness of what I might be experiencing. Initially, she felt very
exposed and frightened by our work together. Eventually, she was able to see me
as a separate person and explored her desire for me as a whole person. During
the early phase of treatment, she apologized whenever I pointed out what she was
doing to me by amputating my desire and self-identity. During this time, she was
under the control of a tyrannical super-ego that cursed her and called her names.
Eventually, she was able to reflect on my feelings of alienation at being treated
like a part object and she expressed sadness for hurting me. This marked
a change in her treatment and her relationship to me. At various times during
the early to middle phases of treatment, she talked about having multiple selves,
to which I responded by talking about her core self as being a unity of
a multiplicity of selves, but above all a self that sought to communicate her hurt
and trauma.
Jacqui developed an attachment to my outer layers (skin, hair, and clothes),
rather than my inner self as a whole object because, at that point in time, she had
no internal representation of a whole, integrated, nurturing object. The
 The Rending of the Skin-Ego and Second Skin 57

emergence of her paraphilia (second skin) in treatment was a first step toward
recovery and treating me as a whole object.
During impasses in treatment, I suggested to Jacqui, who was a trained fine
artist, to bring into treatment some of her artworks. The content of the art was
very primitive. The themes included images and sculptures of penises, women
who were gutted and bleeding, body parts that were marked with self-cutting,
reptiles, snakes, and other frightening objects. Images of raw pornographic desire
were paired with drawings depicting a little frightened and vulnerable child-self
who was hiding next to her therapist. Her images were undefended and included
a child-self hiding behind the therapist or cowering in a corner. We were then
able to explore her feelings in the therapy hour of both idealizing and fearing
being harmed by the me. One of her drawings portrayed a naked therapist,
covered with hair like a feral animal, cuddling with her (her father was very
hairy). It brought up memories of father and his treatment of her as a little boy.
All of her drawings and sculptures reflected prelinguistic and embodied truths
about her adoption, internal self-and-other representations, aggression and sex-
ual desires. They reflected some part of herself that was difficult for her to
verbalize in the therapy hour but also her desire to talk about the unthinkable
in treatment (cf. Creparo & Mucci, 2017). She did some of her best therapeutic
work talking about her art in relation to the transference feelings of her desire for
me, which helped her work through her need for maternal care. As I entered the
therapy hour as a whole object, she was faced with an existential dilemma of
losing the as-if desire of the fetish and being confronted with the reality of me as
a person. This led to months of depression. We worked hard to keep her alive
and hopeful, as she was no longer able to use her hate in the transference to
protect herself from her projections of me as dangerous.
When Jacqui entered treatment 25 years ago, she was nonverbal and unable
to talk. She stared, communicated in fragments of speech, and dissociated. Jacqui
recently wrote to me, “All along, regarding my relationship with you, I thought it
had to do with my desire to have sex and connection. I see now that it was far
more primitive than that. My desire was merely to reconnect with my mother,
a woman I have no conscious knowledge of, who left me after some visits as an
infant. This must have been extremely traumatic for me to have affected me so
deeply and for so long.”

Case 2: Bernard—the Wrong Skin and the Wrong Body: Rage and Mourning

To acquire a skin-ego is to acquire both a physical and a mental skin of one’s own—an
acquisition that does not take place, however, without the traumatic loss of the shared
skin. — LaFrance (2013, p. 25)
58 Leslie M. Lothstein, PhD, ABPP

Bernard was in treatment for 22 years. He was unhappily married with

children. He spent his days drinking and taking drugs, watching porn, and
masturbating frequently. He was a professional in the health-care industry who
was referred for help because of too many mistakes and fatalities associated with
his care, and a suspicion that he was drunk and high during the workday. In fact,
he was using up to 60 Percocets a day and constantly drinking vodka out of a soda
can. I initially saw him as an inpatient. Prior to coming into the hospital, he had
lied to his family about where he was. He was a physical and psychological wreck
with an as-if personality, appearing charming one minute and enraged and
anxious the next.
During the first 2 years of treatment, Bernard was in a constant state of
depression and rage. He talked nonstop and would not allow me to say anything
to him. Once when I asked for clarification, he told me, “Shut up. This is my
therapy.” He was narcissistic and entitled, histrionic and aggressive. He hated his
“small body frame, small arms, legs and genitals.” He blamed his distress on early
childhood trauma at the hands of his mother, whom he believed had sexually
violated and then tried to murder him. His childhood memories were gruesome
and violent; he recalled, for example, his mother putting broken glass in his
mouth and using him as a sex toy for masturbation. He had distinct memories
from age 5 of plotting to kill his mother by driving a knife through her heart. In
addition to being sadistic and sexually inappropriate, his mother was clinically
depressed and inconsolable; Bernard felt responsible for her mental problems
and charted a career path to cure her.
Bernard’s relationship with father was also fraught with anxiety and valoriza-
tion. His father was a war hero with a significant injury to his right leg, wounded
during a parachute jump into enemy territory when he was shot. A particular
memory of father during Bernard’s late adolescence focused on the night before
his exams for professional school, when his father rented a hotel room, wrote
a suicide note, and prepared to jump out the window (perhaps enacting
a memory of his war injury). Bernard was sent to rescue his father and spent
the whole night with him.
Bernard recalls substituting fantasy for reality as a child and told me about
his grandiose fantasies of being the king of the universe. He compared himself to
Jesus and St. Thomas Aquinas. He also struggled with childhood sexual fantasies
about Jesus; in church he viewed a statue of Jesus in what he thought was a diaper
and became excited. He himself yearned for admiration and adoration; his
mother was not present for him during the mirroring phase of his early self-
development, and he substituted grandiose fantasies for love from her. He hated
his body and his skin. He believed that he was born into the wrong skin, which
had never quite stretched into the right-sized body he felt he deserved. He felt
suffocated, trapped, and claustrophobic in his skin. He occasionally walked with
a distinctive limp for which there was no known physical reason, though he
 The Rending of the Skin-Ego and Second Skin 59

related it to the same body part as his father’s war injury. When he was highly
anxious he rubbed that part of his skin that reminded him of his father’s leg. And
when emotionally overwrought, agitated or anxious, Bernard experienced pain in
that same leg but could not get any relief in terms of care and empathy from his
parents. Consequently, he never felt alive in his skin. His somatic symptom
embodied his feelings of inadequacy, self-loathing, and castration anxiety.
In the first few years of treatment he was alternatively enraged and impul-
sively uncontrolled. He experienced intense shame and humiliation at having
been removed from his career and unable to work. When highly anxious he
would hit his “small arms and legs” as a kind of self-injury that made him feel
alive. Bernard was overweight and reeked of tobacco and sometimes of urine, as
he had poor bladder control. His somatic symptoms also included chronic
diarrhea, bloating, and bowel distress that further kept others at a distance.
When he was a child, his teachers and peers had also complained that he smelled
of feces; currently his wife also refused to have sex with him, and he felt
humiliated by her words and actions. In treatment, too, his body odor was
offensive; but it was only in the past 5 years that he could tolerate my commenting
on his olfactory perversion for “shit, urine, and blood” as a way of marking his
territory in the treatment hour and challenging me to tolerate the worst parts of
him. I had the impression that his odors served as a second skin to keep others at
a safe distance. He associated to the fecal odors as aggressive and violent messages
to keep others away, related to his rage toward mother and his intense envy of his
father. His odors pushed others away and foreclosed emotional closeness and
intimacy with most people who knew him. His use of olfactory defenses repre-
sented a violent projection of a self that yearned for intimacy yet projected
himself as a decaying and disgusting object to avoid (Kernberg, 1992). There
was also something about his need for being a putrefying olfactory presence in
treatment that was exciting to him. From a relational standpoint in the transfer-
ence, I had difficulty, at times, staying connected to him, as his scent was off-
putting and sometimes patients coming after him commented on the odors.
During treatment, Bernard’s behavior was occasionally quite primitive. He
frothed at the mouth, crawled on the floor, drooled, banged his fists, and once
threw a pen toward the wall with such ferocity that it embedded in the wall. For 2
years, he refused to let me talk. A year later, he reached out and touched my knee
and said, “You are real! You exist! You’re not just in my mind.” This began a new
phase of treatment in which he allowed me to talk and not just be a witness, and
he acknowledged that I was separate and not a figment of his imagination.
Sometime during the 11th year of treatment, he entered psychologically oriented
massage therapy. Eventually, he was able to undress and get regular/weekly full-
body nonsexual massages that became an enactment of a relationship with
a maternal object who soothed him but did not cross sexual boundaries. When
he talked about his massage therapist, I had the impression that she served
60 Leslie M. Lothstein, PhD, ABPP

a primary, concrete representation of a good maternal object. It appeared that he

needed an actual skin-to-skin, gentle maternal asexual touch to further his pro-
gress in therapy, in which I was now acknowledged as a participant. During the
former phase of treatment, abstract words and a symbolic therapeutic relation-
ship were simply not enough to foster the healing process.
The most difficult parts of Bernard’s treatment focused on the transference;
as I have noted, it took years for him to treat me as a separate person who was not
a paranoid object inside of him trying to either manipulate, trick or kill him.
Although he was on an appropriate regimen of psychotropic medication, it was
only during this final phase of his treatment that working on his embodied
emotional distress in a verbal therapy was acceptable. During this period, he
was able to become calm and self-regulated. My internal emotional states during
the early phase of treatment were like being on a roller coaster and not enjoying
the ride, feeling invisible and unnecessary. However, becoming visible made me
more vulnerable to his rage as he initially deteriorated in a primitive way (testing
me to see if I could stay with him without firing him or harming him) before
reconstituting his self and becoming more able to relate to me as a whole object.
The second skins of protection were still needed, however, as treating me as
a whole object also had its dangers of too much intimacy with a male. At some
point, however, Bernard stopped going to the massage therapist and began plans
to find someone who might be able to tolerate his eccentricities and both desire
and love him.

Case 3: Donald—the Vagina Man

My first and only husband hated hair. He said it was cluttered and dirty. He made me shave my
vagina. It looked puffy and exposed and like a little girl. This excited him. — Ensler (2012, p. 4).

Donald’s paraphilia was an attempt to resolve a multitude of problems. At

the age of 16, Donald had been psychiatrically hospitalized for 1 year for being
out of control (aggressively and sexually), regressed, and conduct disordered.
A profoundly impulsive teenager, he had grown into an impulsive, narcissistic,
and grandiose man. His relationships with women were very unstable; he was
a philanderer who slept with hundreds, if not several thousands, of women. As
a prominent businessman, he attracted a lot of female buyers. He never sold
a product to a woman without having sex with her first, causing many husbands to
hate him and others to leave their spouses. As with these women, he was,
unctuous, was self-preoccupied, and treated me as an after-thought when he
started treatment with me. He enjoyed entertaining me while avoiding intimacy.
He was also a pathological liar, making treatment hinge precariously on the
truths he invented. Pointing this out to him took time, as he was very vulnerable
to criticism.
 The Rending of the Skin-Ego and Second Skin 61

Donald had terrible facial acne that led to intense feelings of shame and
humiliation that prevented him from ever fully disrobing in front of the
women he slept with. He wore expensive European clothing and shoes to
deflect from his skin defects, and the clothing served as his “perfect” second-
skin. His chattiness and vulnerability gave him access to beautiful women who
adored him, despite his skin condition. What the women did not know was that
there were times when, out of sight, he could not recall their names or faces
but could recognize them only by their pubic areas (which he insisted on
shaving himself before sleeping with them) and his olfactory memories of their
vaginas. He had an unusual form of prosopagnosia reminiscent of Rene
Magritte’s famous 1934 picture The Rape, in which the sexual body of
a woman becomes her face.
Donald began treatment with me after experiencing a panic attack when his
closest friend confronted him about seeing Donald having sex with this friend’s
daughter in a parked car. His friend threatened to have him arrested if he didn’t
seek treatment, believing Donald might be a pedophile. Although he was wrong
in his diagnosis, he was of course right about the seriousness of Donald’s dis-
turbance. When treatment began, Donald focused on his amazement that I had
answered the phone when he first called. In the midst of the worst psychological
crisis in his life, he interpreted my picking up the phone as a powerful sign. He
said that for days, up until our first appointment, he kept hearing my voice in his
head, and it soothed him and reminded him of his dead father, whom he missed.
I seemed to become, for Donald, the voice of his father, who I later learned had
died when he was about 10 years old. It was the voice that he missed, probably the
last voice of a person with whom he had had a whole object relationship (cf.
LaGaay, 2008).
Donald’s father’s death triggered a cascading emotional decline, exacer-
bated by his mother’s replacement of the father with an evil stepfather who
wanted him out of the family. I quickly learned that although Donald found his
friend’s daughter beautiful and erotic, he did not want to have sex with her as
much as he wanted to be her, have her skin, and wear her protective beautiful
clothing and youthful skin himself; he believed that had he been beautiful and
female, his stepfather would have loved him more and allowed him to stay at
home. By crawling into the skin of the women he slept with, he solved the
problem of his dermatological skin condition, though only for a brief moment;
he viewed becoming female as solving the problem of his ugly male skin. He also
reported that this conflict appeared in his fantasy enactments, as when while
having sex with his friend’s daughter he fantasized that she was penetrating his
vagina. Donald viewed his skin as both male and female, containing both genital
structures.
The bedrock for Donald’s paraphilia stemmed not only from jealousy of his
sisters but also from a profound adolescent experience he had the day after he
62 Leslie M. Lothstein, PhD, ABPP

was discharged from a 1-year psychiatric hospitalization from ages 14–15. He was
still a child, but a very angry child whose adolescent presence threatened his
stepfather. On the evening of his return home, his mother told him that he could
no longer live at home and was being sent out of state, the next day, to live with
a male couple. Donald became profoundly anxious, filled with dread and trem-
bling with fear and rage. But he was emotionally unprepared for what came next:
His mother curled up beside him in bed and had oral and vaginal intercourse
with him. The next day he left for good, cloaked in his mother’s scent and with
an intense rage and a fulminating paraphilia in which maternal soothing and the
forbidden sexuality of incest and rape were inseparable.
While living with the two men, Donald had bisexual experiences as well as
encounters with transvestites and transsexuals. In the midst of all this sexual
chaos, he settled in with a 17-year-old girlfriend who consolidated and helped
to shape his diffuse sexual-gender identity as heterosexual. Having his first real
girlfriend allowed him to emotionally separate from his male caretakers, but with
women, he developed a paraphilia in which he felt compelled to trim their pubic
hair before he “went down on” or “penetrated” them. He came prepared for
every new sexual encounter with scissors, a razor, shaving cream, and a head
lamp. Allegedly, no woman refused his need to “trim” her pubic area. Many of
the women, he believed, enjoyed the attention. It seems as though through his
paraphilic practice Donald attempted to experience a longed-for skin-to-skin
contact with a maternal figure that had a primitive beginning in his olfactory
senses and the incest with his mother.
The possible link between the pubic hair shaving fetish and his incest with
his mother was never completely understood, though Donald verbalized the idea
that lurking beneath the pubic hair was the mysterious female penis he longed
for (his words) and the mother he needed to stay away from. He also said that
once the hair was removed from a woman’s vagina it was more like a breast and
allowed him to feel emotionally safe and calm. The shaving may also have
represented a compromise between his excitement toward the female teenager
he was accused of being inappropriate toward and his gender dysphoria; in some
fundamental way, Donald wanted to be, not have, a woman.
Donald’s core embodied trauma fantasy focused on his incest experience
with mother. He believed that the stain of adolescent incest infected the surface
of his body with severe acne that literally scarred him for life and covered him
with shame memories that were embodied on the whole surface of his body
(particularly his face and back). After that experience he could never believe
that he was capable of being loved. As an adult, he would, after sex, become
enraged and emotionally attack and abuse his partner, acting out his unexpressed
rage toward the mother whose “incest gift” left him permanently scarred and
emotionally stuck in a perpetual state of shame, impotency, and rage. We
explored whether his female-skin fantasy (to become female and only date and
 The Rending of the Skin-Ego and Second Skin 63

live with beautiful women he could not have sex with) may have allowed him
some relief from the incest terror and retaliatory urges he experienced and which
left him in a state of high anxiety.
Donald’s fantasy of developing smooth skin also reflected his narcissistic wish
to escape the confines of his ugly skin and male body, which was covered with
acne scars. Looking at himself in the mirror as a female, Donald felt whole.

Discussion

The body serves the primary function of managing unconscious anxieties and conflicts that
cannot be reflected upon. — Lemma (2010, p. 21)
I hope to show that … human subjectivity (is) “completely psychic, utterly somatic,
essentially intersubjective and intercorporeal, constantly changing … and fundamentally
located in space and time.” (Lafrance, 2009, p. 19)

Paraphilia is the final common pathway of a damaged self in search of

a solution to suffering. It emerges out of a ruptured and vulnerable skin-ego as
a pseudosolution to unique relational problems of attachment, intimacy, and love
relationships. The paraphilia is rooted in early sensory processes, is intersubjec-
tive, arises in the inter corporeal process of the mother–child relational matrix,
and later causes emotional irruptions between partners.
It was hard not to notice Donald’s irrupting skin pustules and not feel his
shame and disgust. I did not need to ask, “What is it that you do not want to talk
about today?” when his body was streaming subjectivity through its skin.
Whenever Donald became hypomanic and frantically used words to deflect
from his skin, his stigmata were never the less still present in the room as
a somatic presence. Similarly, when Jacqui presented with layers of clothing, an
intense Mona Lisa smile, and silence (suggesting the possibility of violence), the
hiddenness of her skin beneath the layered armoring of her clothing still cried
out to be heard as a dangerous body for me to see and hear. And when Bernard’s
odorous body left its presence in every nook and cranny of my office (even for
other patients to experience), I found myself holding him in olfactory memory
throughout the rest of the day, his skin’s smell becoming a part of my subjectivity.
Beneath these three patients’ somatic paraphilias were themes of abandon-
ment, maternal rage and violence, intense interpersonal rage, and addiction
(primarily toward alcohol, except in Donald, who was diabetic and had to limit
his drinking as he got older). To help them, I used my emergent feelings
relationally to focus on what they did not want to talk about in therapy. I also
asked where in their bodies they experienced their paranoid fears of my words as
bodily intrusions and injuries to their selves via rentings in their present-day skin-
egos. Only after extensive gentle probing were they able to talk about unspeak-
able skin-ego traumas from childhood. Donald eventually admitted to being
64 Leslie M. Lothstein, PhD, ABPP

a pathological liar. Bernard admitted that his boasting of childhood achievements

in baseball were complete distortions of reality. Jacqui began to step back from
her assertion that she had a photographic memory for what I said to her in
treatment. She also wrestled with her dissociation (akin to blackout states and loss
of memory), as when I confronted her primitive psychotic violence in the trans-
ference and she admitted, in the second year of treatment, to having stalked my
wife and dog, planning to kill them both so that she could have me all to herself.
In paraphilia, internal conflicts and contradicting yearnings for, and disap-
pointment in, maternal care are projected onto the surface of the skin and form
the basis for later paraphilic development. The paraphilia is embedded in the
latticework of a nascent self that fears fusion with the maternal object, yet yearns
for relational connection. In a paradoxical way, paraphilias are the antithesis to the
formation of genuine intimacy. Having been established in childhood as a defense
against the dangers of traumatic, toxic intimacy and connection, they continue to
keep the sufferer at a distance and serve as a defense against depression, despair,
low self-esteem, fusion with the object, shame, and secondary rage.
In each case discussed here, the relational transference of the paraphilia was
confronted, discussed, and interpreted. Each of the patients initially related to
me as a part-object and only over a prolonged period were they able to mourn
the damaged maternal–infant relationship and find themselves able to express
genuine love for the therapist and an ability to give up the fetish that dominated
their lives and disconnected them from any hope of genuine love and intimacy.
The patients described in this paper had various forms of primitive emo-
tional pathology with borderline and narcissistic self-structures, as well as a form
of gender diffusion. All three patients fit into Kohut and Wolf’s (1978) diagnostic
schema of the self-disorders associated with primitive narcissistic disorders along
psychotic lines. In all three cases, the paraphilia was rooted in the vulnerabilities
of the primary sensory skin-ego defects (a failure in mirroring and idealization)
and shaped by a number of environmental issues related to family and intersub-
jective processes. The skin became the focus of their pathology. All of this was
used intersubjectively and relationally in the transference, facilitated by the
therapeutic approach of a mind–body unity, not a split, and the focus on the
body–soma–mind as concealing all the crucial memories of early trauma that
needed to be given a sensory-voice before skin-ego renting could be repaired.
The patients’ early trauma involved either deprivation or overstimulation, which
caused permanent primary narcissistic injuries to core self-development and
primary rendings of the skin-ego, the earliest damage to the infant psyche.
Our understanding of the nature of paraphilia bears great implications for its
treatment. Bick’s and Anzieu’s work provides us with a different knowledge-base of
the role of skin and skin-ego in self-development, psychosexuality, and relationality.
The best way to treat paraphilias is by healing and repairing the skin-ego. Attempts to
repair the rifts and splits in the self using therapeutic modalities that are primarily
 The Rending of the Skin-Ego and Second Skin 65

language-based alone are bound to fail. The successful therapy of paraphilias must
include non-language-based interventions drawing on the underlying embodied
transferences in the relational dynamics of the patient–therapist dyad. In all three
cases presented here, the use of art, body odors, and bodily inscriptions became the
gateway to talking about the body, interpersonal boundaries, and early traumatic
memories.
Treatments for the paraphilias must begin with a focus on the embodied
memories, the ruptured skin-ego and dissociation, and denial of reality of the
subjectivities of others. In all three cases, boundaries with others were absent or
too permeable at the outset of treatment; verbal approaches to treatment did not
allow for more primitive somatic anxieties to be expressed and for the soma to be
addressed as the critical factor in later symptom formation.
The challenge for the therapist is to listen to such patients at a deeper level
of mind-sight and to have a high tolerance for attending to primitive psychotic
material that is embedded in personality structure. The therapeutic process
cannot proceed without the therapist having the ability to tolerate intense rage,
disgust, threats, violence, and primitive sexualities erupting in the transference.
For some therapists, there is a tendency to retreat and “get rid of” these patients
as they arouse too much anxiety. Moreover, although sex and the body may be at
the forefront of contemporary relational psychoanalysis (cf. Atlas, 2016; Benjamin
& Atlas, 2015), there is tendency to objectify dangerous sexuality (Bering, 2013)
while avoiding a recognition that everything patients present to us is part of our
own early childhood fantasy and experience, though fashioned uniquely around
our own early relational family dynamics. Craparo and Mucci (2017) reminded us
of the need to focus on the unrepressed, unconscious, and implicit memory that
lives within all of us, even for early childhood trauma memories (see also Coates,
2016; Coates & Moore, 1997; Van der Kolk, 1994).
A final difficulty of treating patients with perversions is their tendency to
bring their excitement (and denial) into the therapy and place a burden on
therapists who are wary of a relational approach to treatment where sexual
enactment becomes too real and potentially dangerous. This is something we
need to address, as a profession, in much more detail. Not everyone can be as
relationally expressive and self-confident in discussing feelings about sex in the
transferences as Atlas (2016) or Celenza (2010), but there is gold in that psycho-
analytic mine.

Disclosure statement

No potential conflict of interest was reported by the author.

66 Leslie M. Lothstein, PhD, ABPP

References

Anzieu. (1999). The group ego-skin. Group Analysis, 32, 319–329. doi:10.1177/05333169922076860
Anzieu, D. (1989). The skin ego: A psychoanalytic approach to the self. Translated by Chris Turner. New
Haven, CT: Yale University Press.
Anzieu, D. (1990). Psychic envelopes. (D. Briggs, Trans.). London, UK: Karnac.
Anzieu, D., & Tarrab, G., Eds. (1990). A skin for thought: Interviews with Gilbert Tarrab on psychology and
psychoanalysis. (G. Tarrab, Trans.). London, UK: Karnac.
Atlas, G. (2016). The enigma of desire: Sex longing and belonging in psychoanalysis. New York, NY:
Routledge.
Benjamin, J., & Atlas, G. (2015). The ‘too muchness’ of excitement:Sexuality in light of excess,
attachment and affect regulation. International Journal of Psychoanalysis, 96, 39–63. doi:10.1111/
1745-8315.12285
Benthian, C. (2002). Skin: On the cultural border between self and the world. New York, NY: Columbia
University Press.
Bering, J. (2013). PERV, the sexual deviant in all of us. New York, NY: Scientific American.
Bhugra, D., Popelyuk, D., & McMullen. (2010). Paraphilias across cultures: Contexts and
controversies. Journal Sex Research, 47(2), 242–256. doi:10.1080/00224491003699833
Bick, E. (1968). The experience of the skin in early object relations. International Journal of
Psychoanalysis, 49, 484–486.
Bick, E. (1986). Further considerations on the function of the skin in early object relations:
Findings from infant observation integrated into child and adult analysis. British Journal of
Psychotherapy, 2, 292–299. doi:10.1111/bjp.1986.2.issue-4
Bick, E. (2002). Further considerations on the function of the skin in early object relations. In
A. Briggs (Ed.), Surviving space: Papers on infant observation (pp. 60–71). London, UK: Karnac.
Cavanagh, S., Faller, A., & Hurst, R. (Eds.). (2013). Skin, culture and psychoanalysis. New York, NY:
Palgrave Macmillan.
Celenza, A. (2010). The guilty pleasure of erotic counter transference: Searching for radial true.
Studies in Gender and Sexuality, 11(4), 175–183. doi:10.1080/15240657.2010.513222
Cheney, T. (2008). Manic: A Memoir. New York, NY: Harper.
Cheng, A. (2010). Second Skin: Josephine Baker and the modern surface. Oxford, UK: Oxford University
Press.
Coates, S., & Moore, M. (1997). The complexity of early trauma: Representation and
transformation. Psychoanalytic Inquiry, 17, 286–311. doi:10.1080/07351699709534128
Coates, S. W. (2016). Can babies remember trauma? Symbolic forms of representation in trauma-
tized infants. Journal of American Psychoanalytic Association, 64(4), 751–776. doi:10.1177/
0003065116659443
Connor, S. (2004). The book of skin. London, UK: Reaktion Books.
Craparo, G., & Mucci, C. (2017). Unrepressed unconscious, implicit memory, and clinical work. London,
UK: Karnac.
Diamond, N. (2013). Between skins: The body in psychoanalysis- contemporary developments. London, UK:
Wiley-Blackwell.
Elmendorf, D. (2007). Containment and the use of the skin. In J. M. Muller & J. G. Tilllman (Eds.),
The embodied subject: Minding the body in psychoanalysis (pp. 81–91). New York, NY: Jason Aronson.
Ensler, E. (2012). Inspiring quotes from vagina warrior Eve Ensler. Retrieved from http://intent-
blog.com/5-inspiring-quotes-from-vagina-warrior-eve-ensler/.
Fannon, F. (1952). Black skin, white masks. (R. Philcox, Trans.). NewYork, NY: Grove Press.
Faulkner, W. (1951). Requiem for a nun. New York, NY: Random House.
 The Rending of the Skin-Ego and Second Skin 67

Feldman, B. (2004). A skin for the imaginal. Journal of Analytical Psychology, 49, 285–311. doi:10.1111/
j.1465-5922.2004.00463.x
Fisher, H. (2005). Why we love: The nature and chemistry of romantic love. New York, NY: Henry Holt
Macmillan.
Fonagy, P. (1999). Attachment theory and psychoanalysis. New York, NY: Other Press.
Fonagy, P., Gergelov, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization and the
development of self. New York, NY: Other Press.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to
the problems of impaired infant- mother relationships. Journal of American Academy of Child
Psychiatry, 14, 387–421. doi:10.1016/S0002-7138(09)61442-4
Gallagher, S. (2005). How the body shapes the mind. Oxford, UK: Oxford University Press.
Goldberg, A. (1995). The problem of perversion. New Haven, CT: Yale University Press.
Goldberg, A. (1999). Being of two minds. Hillsdale, NJ: Analytic Press.
Goldberg, A. (Ed.). (2000). Errant selves: A casebook of misbehavior. Hillsdale, NJ: Analytic Press.
Harris, A., Kalb, M., & Klebanoff, S. (Eds.). (2016). Ghosts in the consulting room: Echoes of trauma in
psychoanalysis. New York, NY: Routledge.
Hiller, J. (2004). Speculations on the links between feeling, emotions and sexual behavior, are
vasopressin and oxytocin involved? Sexual and Relationship Therapy, 19(4), 393–412. doi:10.1080/
14681990412331297974
Houzel, D. (1996). The family envelope and what happens when it is torn. International Journal of
Psychoanalysis, 77, 901–912.
Jablonski, N. (2006). Skin: A natural history. Berkeley, CA: Berkeley University of California Press.
Jimenez, J. P., & Moguillansky, R. (Eds.). (2011). Clinical and theoretical aspects of perversion: The
illusory bond. London, UK: Karnac.
Joyce, J. (1977). James Joyce in Padua. Trans. and Ed. Louis Berrone. New York, NY: Random House.
Kaplan. (1991). Female perversions. New York, NY: Doubleday.
Karr-Morse, R., & Wiley, M. (2013). Ghosts from the Nursery: Tracing the roots of violence. New York, NY:
Atlantic Monthly Press.
Katehakis, A. (2016). Sex addiction as affect regulation: A neurobiologically informed holistic treatment.
New York, NY: Norton
Kernberg, O. (1992). Aggression in personality disorders and perversions. New Haven, CT: Yale University Press.
Kernberg, O., Burstein, E., Coyne, L., Appelbaumn, A., Horwitz, L., & Voth, H. (1972).
Psychotherapy and psychoanalysis: Final report of the Menninger foundation’s psychotherapy
research project. Bulletin of the Menninger Clinic, 36, 3–75.
Khan, M. (1979). Alienation in perversions. New York, NY: International University Press.
Kilby, J. (2001). Carved in skin: Bearing witness to self harm. In S. Ahmed & J. Stacey (Eds.),
Thinking through the skin (pp. 124–142). London, UK: Routledge.
Klein, M. (1930). The Importance of symbol-formation in the development of the ego. International
Journal of Psycho-Analysis, 11, 24–39.
Kohut, H. (1977). The restoration of the self. New York, NY: International Universities Press.
Kohut, H. (1979). The two analyses of Mr. Z. International Journal of Psycho-Analysis, 60, 5–27.
Kohut, H., & Wolf, E. S. (1978). The Disorders of the self and their treatment: An outline.
International Journal of Psycho-Analysis, 59, 413–425.
Lafrance, M. (2009). Skin and the self: Cultural theory and anglo, American Psychoanalysis. Body
and Society, 15, 19–24. doi:10.1177/1357034X09339099
LaFrance, M. (2013). From the skin ego to the psychic envelope: An introduction to the work of
Didier Anzieu. In S. Cavanagh, A. Faller, & R. Hurst (Eds.), Skin, culture and psychoanalysis (pp.
16–44). New York, NY: Palgrave Macmillan.
68 Leslie M. Lothstein, PhD, ABPP

LaGaay, A. (2008) Between sound and silence: Voice in the history of psychoanalysis. Retrieved
from http://research.ncl.ac.uk/e-isteme/issues/issue01/contents/e-pisteme%20Vol.%201(1)%
20-%20Alice%20Lagaay%20(Full%20Text).pdf
Lemma, A. (2010). Under the skin: A psychoanalytic study of body modification. New York, NY: Routledge.
Lemma, A. (2015). Minding the body: The body in psychoanalysis and beyond. London, UK: Routledge.
Lothstein, L. (1988). Self -object failure and gender identity. In A. Goldberg (Ed.), Frontiers in self
psychology: Progress in self psychology, 1988. Vol. III (pp. 213–235). Hillsdale, NJ: Analytic Press.
Lothstein, L. (1995). An olfactory perversion (osmophilia) successfully treated using Depo-Provera and
then psychotherapy. Sexual Addiction and Compulsivity, 2, 40–53. doi:10.1080/10720169508400065
Lothstein, L. (1997). Pantyhose fetishism and self cohesion: A paraphilic solution? Gender and
Psychoanalysis, 2, 103–121.
Mellier, D. (2014). The psychic envelopes in psychoanalytic theories of infancy. Frontiers in
Psychology, 5, 1–9. doi:10.3389/fpsyg.2014.00001
Money, J. (1986). Lovemaps. New York, NY: Irvington Books.
North, S. (2013). The surfacing of the self: The clothing-ego. In A. Cavanagh, A. Faller, & R. Hurst
(Eds.), Skin, culture and psychoanalysis (pp. 64–89). New York, NY: Palgrave Macmillan.
Pile, S. (2009). Topographies of the body-and-Mind: Skin ego, body ego and the film “Memento”.
Subjectivity: International Journal of Critical Psychology, 27(1), 134–154. doi:10.1057/sub.2009.7
Pile, S. (2011). Spatialities of skin: The chafing of skin ego and second skins. In T.E. Lawrence’s Seven
Pillars of Wisdom. Body and Society, 17(4), 57–81.
Pines, D. (1980). Skin communications: Early skin disorders and their effect on transference.
International Journal of Psycho-Analysis, 61, 315–323.
Prosser, J. (1998). Second skins: The body narratives of transsexuality. New York, NY: Columbia University Press.
Raufman, R., & Weinberg, H. (2016). “To enter one’s skin”: The concrete and symbolic functions
of the skin in the social unconscious, as expressed in fairy tales and group therapy. International
Journal of Group Psychotherapy, 66, 205–224. doi:10.1080/00207284.2015.1106182
Raufman, R., & Yagael, Y. (2011). Feeling good in your own skin, Part II: Idiomatic expressions-the
language’s way to connect with the primary levels of mental organization. American Journal of
Psychoanalysis, 71, 16–36. doi:10.1057/ajp.2010.33
Schore, A. (2003a). Affect dysregulation and disorder of the self. New York, NY: Norton.
Schore, A. (2003b). Affect regulation and the repair of the self.
Schwartz, M. (2008). Developmental psychopathological perspectives onsexually compulsive behavior.
Retrieved from http://www.castlewoodtc.com/wpcontent/uploads/2011/07/mark_pcna.pdf
Schwartz, M. F., & Southern, S. (1999). Manifestations of damaged development of the humans
affectional systems and developmentally based psychotherapies. Sexual Addiction and Compulsivity,
6, 163–175. doi:10.1080/10720169908400190
Segal, H. (1965). Notes on symbol formation. International Journal of Psycho-Analysis, 38, 391–397.
Shengold, L. (1989). Soul murder: The effects of childhood abuse and deprivation. New Haven, CT: Yale
University Press.
Stern, D. (1985). The interpersonal world of the infant. New York, NY: Basic Books.
Stoller, R. (1975). Perversion as the erotic form of hatred. New York, NY: Pantheon.
Stoller, R. (1991). Pain and passion: A psychoanalyst explores the world of S & M. New York, NY: Plenum.
Thompson, S. (2013). Disrupting the skin–Ego: See sickness and the read in the flagellation of
a virgin. In S. Cavanagh, A. Faller, & R. Hurst (Eds.), Skin, culture and psychoanalysis (pp. 215–
239). New York, NY: Palgrave Macmillan.
Turp, M. (2007). Self harm by omission: A question of skin containment. Psychodynamic Practice, 13
(3), 229–244. doi:10.1080/14753630701455812
Tustin, F. (1990). The protective shell in children and adults. London, UK: Karnac.
 The Rending of the Skin-Ego and Second Skin 69

Tyler, I. (2001). Skin tight, celebrity, pregnancy and subjectivity. In S. Ahmed & J. Stacey (Eds.),
Thinking through the skin (pp. 69–84). London, UK: Routledge.
Ulnik, J. (2007). Skin in psychoanalysis. London, UK: Karnac.
Van Der Kolk, B. (1994). The body keeps the score: Memory and he evolving psychobiology of post
traumatic stress. Harvard Review of Psychiatry, 1(5), 253–265.
Vivona, J. (2009). Embodied language in neuroscience and psychoanalysis. Journal of American
Psychoanalytic Association, 57, 1327–1360. doi:10.1177/0003065109352903
Yeats, W. B. (1933). Crazy Jane Talks with the Bishop. In Richard J. Finneran (Ed.) The Poems of W.
B. Yeats: A New Edition. Copyright 1933 by Macmillan Publishing Company, renewed copyright
1961 by Georgie Yeats.

Contributor

Leslie M. Lothstein, PhD, ABPP, is an Associate Professor at Case Western Reserve University,
Department of Psychiatry, and on the faculty at Yale University, Lecturer in Law and
Psychiatry.