REVIEW PAPER

Psychoanalytic Contributions to the

Study of Gender Issues
1
Norma B Barbieri, MD, FRCPC

Objective: To explore the issue of gender development and its applications and implications with respect to
dynamic psychiatry.
Method: Gender study is approached in this paper as a continually evolving process ofthinking about male and
female attributes, similarities, anddifferences. Thepaper reviews a specific thematic area ofthe extensive literature
on the subject.
Results: Gendered psychosexual development and identity construction are intertwined and determined by
multibiopsychosocial factors. Freud's theory on femininity is briefly reviewed from the perspective of new
theoretical developments.
Conclusions: The paper highlights the fact that gender is becoming a useful conceptual tool in clinical practice,
teaching, and neurosciences.

(Can J Psychiatry 1999;44:72-76)

Key Words: gender, dynamic psychiatry, psychoanalysis, femininity, postmodernism

ome events ofuniversal interest leading to new theoretical
S developments usually have triggered controversies and
deep internal malaise. Indeed, Copernicus's heliocentrism
(1473) was at the origin ofthe scientific revolution ofthe 17th
century. Darwin was harshly criticized by the Church when
he showed that humans descended from the animal species
(1859). Engels' historical materialism (1850) was rejected as
a scientific method of explaining the phenomenon of human-
kind's alienation in relation to the economical structure of
society. A century ago, Freud's ideas were assailed from
every quarter when he founded psychoanalysis as a theory and
as a method of treatment for neuroses.
Manuscript received March 1998, revised, and accepted June 1998.
A more detailed version ofthe original manuscript was presented for internal
use, as a training requirement, to the Canadian Psychoanalytic Institute,
Quebec English Branch, in May 1997.
1Medical Lecturer, affiliated with the University ofOttawa, Ottawa, Ontario.
Addressfor correspondence: Dr NB Barbieri, 117 Murray Street, Suite 201,
Ottawa, ON KIN 5M5
email: barbieri@istar.ca
Can) Psychiatry, Vol44, February 1999
72
Psychosexual development, psychic determinism, andthe
dynamic unconscious are evidence ofthe subjection of reason
to impulses. Like a key unlocking the unconscious, contem-
porary gender theories stress not only that the ego is under the
influence of the id but also that the id, like genetic material,
has male and female impulses. Indeed, gender issues furnish
the basis for new concepts and far-reaching theories, which
defines a historical moment in the development of scientific
knowledge with great impact on clinical practice, teaching,
and research.
Among its many contributions to the development of
psychodynamic psychiatry (1) during the first half of this
century, psychoanalytic theory played an important role inthe
treatment of the mentally disordered. However, at that time,
therapeutic choices were scarce. Branching out from psycho-
analysis, short-term dynamic therapies, crisis intervention,
and cognitive approaches emerged as part of the community
mental health movement in the post-World War II period.
Reliance on relatively brief treatments was primarily for
economic and ideological reasons; the concern at that time
was to fmd effective strategies to help numerous patients.
Febroary 1999 Gender Issues and Psychoanalysis
Psychoanalysis and other mentalistic approaches have be-
come an accepted field of clinical and scientific research (2),
while during the last 4 decades, as it is known, the steady
growth of biological psychiatry has led to a "remedicaliza-
tion" of psychiatry. Numerous advances in the therapeutic
armamentarium of psychiatry have been made: there now is
new psychotropic medication to treat illnesses, and even
psychoanalysts are no longer reluctant to have proper medi-
cation prescribed when it is needed. Likewise, to enhance the
therapeutic effects of pharmacologic and community ap-
proaches, dynamic thinking again fmds a place in the man-
agement of clinical impasses and refractory cases and in the
treatment ofthe "difficult" patient (Axis II diagnoses), among
others. The study of resistance and defence shows how the
patient deals with conflicts, protects secrets, and avoids un-
pleasant feelings that hinder treatment. Hence, psychopathol-
ogy is linked to unconscious meaning; resistances are enacted
in treatment in relation to the fears of giving up the wish to
get well (3,4).
At the end ofthe 20th century, with the advent ofpostmod-
ernism and the rising tide of feminism, knowledge derived
from many disciplines has gradually been integrated. Gender
issues pervade everyday life, becoming a popular topic in
public discourse through the media, films, fashion, the arts,
sciences, politics, legislation, the military, economics, relig-
ion, education, and women-related issues on campus. On a
relative score, during the 6th annual National Survey of
Canadian Doctors (5), a gender-based difference in opinion
regarding the prescription ofpsychotropic drugs, among other
things, was noted.
Historical Evolution of "Gender" in Psychoanalytic
Thinking
One century ago, in keeping with the socioideological
context of the time, Freud's theory of the unconscious and
infantile sexuality was partly based on male-biased concepts.
In his monosexual theory, Freud saw nature as masculine, and
he tried to accommodate biology and psychology within male
anatomy. "Anatomy is destiny" was Freud's shibboleth (6).
For him, narcissistic completion was equated with having a
penis, and narcissistic inferiority, proper to women, was
traced to not having a penis. For Freud, the bedrock ofwomen
was penis envy, shame was a female emotion related to
weakness, and repression at puberty was required before the
clitoris gave way to the vagina and masculinity to femininity
(7). He distinuished between sexual and genital concepts and
referred to the castration complex as a psychic organizer.
The validity ofmany of Freud's ideas were disputed since
they did not reflect women's experiences. During the 1920s
and 1930s, some of Freud's contemporaries participated in
the first debate on femininity to focus on penis envy and
subsequently motherhood (8), thus furthering the psychoana-
lytic conceptualization on femininity. For Abraham (9), Klein
(10,11), and other followers of the English school, psy-
73
chosexual receptiveness in a girl was associated with a greater
capacity for interiorization of her parents. In addition, Jones
(12), Homey (13), and Jacobson (14) concluded that the girl
adopted a primary feminine position according to her own
distinctive anatomy and psychology. Gradually, the Freudian
father-centred focus shifted to a mother-centred approach,
highlighting interpersonal and maternal determinants ofmen-
tal development. The centrality of the preoedipal maternal
determinants in pathology and treatment was well empha-
sized by Winnicott (15,16). He is known for many important
concepts, including the good enough mother, the transitional
object and space, illusionment and disillusionment phenom-
ena, and the false self related to the failure in the holding
environment. Kohut shared his opinion about the role of the
caregiver in emotional maturation (17). He saw narcissistic
development as a mirror of the internal state of the infant.
In 1955, Money proposed the use ofthe term "gender role"
in the health sciences to refer to the social behaviour attributed
to and displayed by men and women (18,19). The concept was
then taken up by Stoller, who introduced a distinction between
sex and gender (20,21): sex refers to the biological fact of
being male or female, whereas gender indicates the prepon-
derant amount of masculinity or femininity found in a single
person. Core gender identity is, to Stoller, the overall sense of
"being a male or a female," present in a child in the first year
of life. Money and Ehrhardt further defined gender identity
as the private experience ofgender role and gender role as the
public expression of gender identity (18). Friedman enumer-
ated different pathological categories related to gender iden-
tity disturbances in childhood (22).
During the 1970s and 1980s, the second debate on femi-
ninity centred on the issues of gender identity with a rap-
prochement of psychoanalysis, biology, and sociology
(23-25). Scientists such as Keller agree on an autonomous
line of development in women and on the centrality of the
mother-daughter relationship as a determinant of femininity
(26). Chodorow explains that, whereas initial oneness with
the mother is long-lasting in girls, it is rapidly rejected in boys,
thereby forging a precocious separate route to masculine
identity (27). Benjamin draws attention to the importance of
identification with both parents in the development ofgender
identity (28). Person studied the role of culture in fantasy
formation (29); she describes female and male fantasies re-
lated to cultural stereotypes of male and female sexuality. In
the context ofdefensive dynamics, Begoin referred to Freud's
refusal offemininity as a defence against depression, splitting
from the depressive feelings contained in the female part of
personality (30). Besides Chasseguet-Smirgel (31), Birksted-
Breen (32) shared the same viewpoint and discussed it as a
manic or phallic defence against the mothering part of per-
sonality. She sees penis envy as phallic envy and distinguishes
it from the more evolved mental representation of the penis
as link, which relates to the depressive position and to the
74 The Canadian Journal of Psychiatry
acknowledgement of the father's presence as an intrapsychi-
cal dimension of separation and reality.
Gender Differences in Male and Female Psychological
Development
In addition to genetics and embryology, neuroendocrinol-
ogy plays a decisive role in studying the interdependent and
multifarious factors required for establishing gender identity.
Among the various hypotheses, it has been mentioned that
prenatal maternal stress syndrome (33) could be responsible
for a deficient androgenization of the brain during a crucial
moment (days 18-19) of brain differentiation and organiza-
tion. Partial male androgenization of the brain could lead to
dimorphic behaviour and homosexuality starting at puberty.
At birth, there is a biological assignment of sex, but paren-
tal attitudes and fantasies are important in defming the gender
role in which the child will be reared. Psychoanalytic infant
observational research has focused on the importance of the
emotional availability of the mother, the presence of the
father, early development, and early mother-child interac-
tions (34,35). Early affectomotor responses and sensorimotor
patterns seem to contribute to the establishment of gender
differences. Female neonates show earlier neurologic matur-
ity (36) and preferences for early vocalization (37) and long
gazing (38), thus enhancing connectedness with the mother.
Male neonates show greater aggressiveness and preferences
for motor responses, thus increasing experiences of separa-
tion. Stoller affirms that, for both boys and girls, there is an
early stage of fusion with the mother, a stage of"protofemin-
inity" or sense of femaleness in both sexes. The girl's sense
of oneness with the mother is a conflict-free aspect that helps
her to establish a sense of femaleness. Conversely, the boy's
transition from the attachment to the mother to the attachment
to the father seems to be traumatic, because the primary
relationship with his mother does not necessarily promote
masculinity. Boys are more task-oriented; they prefer muscu-
lar activities and rough play and generally need a greater
assertive experience of the ego boundaries. Tyson defmes a
first stage during which developmental tasks impact the nar-
cissistic consolidation of the body image (39). The availabil-
ity of the father as a male model for the son helps to loosen
the symbiotic ties with the mother and to establish a sense of
primary masculinity. Greenson refers to this as "dis-identify-
ing" from the mother (40). The second stage, defmed by the
oedipal and castration complexes, deals with the assumption
and practice of a male gender role as well as transformation
in fantasies about the loved parental figures. During the
adolescent individuation process in particular, same-gender
dyadic issues (the preoedipal attachments and deidealization
ofthe father reported by Bloss [41]) resurface. For both boys
and girls, same- and cross-gender identification with both
parents is important for consolidation of gender identity.
Latency and puberty are important for consolidation ofgender
identity, gender role, and sexual partner orientation.
Vol44,Nol
Thus, the continuous and never-ending process ofprogres-
sion and differentiation is set in motion very early. The
interiorization of experiences, rules, norms, and linguistic
forms that are natural and appropriate for boys and girls
shapes gender. Cognitive maturation, recognition of bounda-
ries, and identification of similarities and distinctions be-
tween the sexes are all part of becoming aware of sex and
gender differences.
Clinical Considerations
Psychopathology
Prevalence studies reveal that the incidence of certain
types of mental disturbances, such as gender identity disor-
ders, alcohol-related disorders, antisocial personality disor-
ders, pyromania, and pathological gambling, is higher among
males (42). In the case of females, there is a higher incidence
of depressive, anxiety, eating, somatic, and dissociative dis-
orders; all of these are associated with a high incidence of
sexual abuse in early life (2 or 3 times more common in girls
than boys) (43).
Greenson believes that the continuity of the symbiotic
relationship with the mother and the sense of femaleness and
gender identity in girls could explain the low incidence of
severe gender disorders in women compared with men. Gen-
der differences have been shown to be striking in other areas
like phenomenology, clinical evolution, treatment response,
and outcome of illness. Further, it seems that there is enough
data to demonstrate an important problem of gender bias in
clinical and research studies, including psychopharmacologi-
cal investigations in which the population tested is predomi-
nantly male and results are automatically extrapolated to
women (44).
Gender disorders per se include patients with and without
sexual abnormalities such as transvestism, transsexualism,
and other paraphilias. Occasional transient minor gender dis-
turbances are virtually ubiquitous. They can be found in
neuroses and in many personality disorders.
Sexual violations continue to occur despite well-publi-
cized clinical and ethical prohibitions. Gartrell and others
reported that, in the case ofmental health professionals, there
is a much higher prevalence of sexual boundary violations
among male therapists (45). Twemlow and Gabbard found
that aggressors are typically middle-aged males (46). Among
the transgressors, psychotic disorders are rare; predatory psy-
chopathic and paraphiliac types, including severe narcissistic
personalities with antisocial features, comprise the largest
group and are almost always male. Masochistic surrender in
the therapist is again more frequent among male therapists.
Although the lovesick type of transgressor is also more fre-
quent in men, it is the most frequent type in female therapist
transgressors as well.
February 1999 Gender Issues and Psychoanalysis
Gender Awarenessand Theoretical Contributions to Psy-
chodynamic Practice
Many clinical studies have focused on gender differences
in the 4 therapeutic dyads and their implications for the
process and outcome of treatments. After studying these
issues, Person, Meyers, and Moldawsky concluded that "In-
itial transference, transference sequences, length and intensity
of transference manifestations are influenced by the gender
of the analyst and the differences within the four possible
gender dyads" (47). Along the same lines, Mendell stated that
the male supervisee could benefit from working with a female
supervisor when it comes to dealing with preoedipal transfer-
ence in a female patient (48). Focusing on gender and thera-
peutic boundaries, Gabbard and Lester affirm that gender
differences and interpersonal boundaries (female permeabil-
ity versus male thickening) influence the treatment process
and that women, more frequently than men, develop erotized
transference onto a female or male analyst (49). Lester ex-
plains further how in the female-female dyad the excessive
connectedness of the therapist (a trained psychodynamic
therapist) can trigger a therapeutic impasse (50,51). In gen-
eral, however, female therapists seem to be more able to
contain stronger preoedipal maternal transference. Lester also
holds that the working through of maternal identification is
necessary to promote separation and individuation before
reaching the stage of real oedipal transference. Some male
therapists are less able to tolerate intense feelings and wishes
for merging. At times, this intolerance might trigger defensive
countertransference reactions that lead to too much detach-
ment or oedipalization of the dyadic transference. Data con-
cerning paternal transference onto a female therapist is
somewhat controversial. Some authors believe that male pa-
tients can fully experience passive unconscious wishes with
female therapists. Other authors believe that passive wishes
linked to paternal transference are often transient or mild or
may be defended against with the remnants of a previous
maternal transference that was perceived as a threat to mas-
culine identity.
Discussion and Conclusion
It follows from the above-mentioned literature that, during
the last 2 or 3 decades, several theoretical contributions to the
concept of gender have been made. From a biological view-
point, Notman and others mentioned several works on the
issues ofhormones, genetics, neurotransmission, hemispheric
specialization, infant research, and potential for connected-
ness to the caregiver (52). Anthropological and sociocultural
studies are also worth mentioning, particularly their consen-
sual thesis about the role of aggression and preference for
motor response in the establishment of male identity. Reiter
reported that anthropological studies on women have shown
that scientific knowledge has been strongly male-oriented
(53). Other studies focus on the function of myth and chil-
75
dren's fairy tales and fantasy world, thereby contributing to
the understanding of gender differences.
From a psychoanalytic perspective, gender identity is the
result of a very complex development that is dialectically
related to a more global developmental process of mental
growth. Gender, psychosexual, and identity development are
all intertwined. Masculinity and femininity are largely con-
structed by interpersonal transactions in the intersubjective
field at a given time and in a particular culture.
The advantages of this new knowledge for the use of
psychiatry are many. The concept of gender is used not only
as a tool for psychodynamic comprehension of development
and pathology but also as an operative concept in clinical
practice. The concept of gender also is being studied and
applied in the area of teaching and in the clinical supervision
processes.
The enormous, growing body of knowledge on gender
issues requires synthesis, integration, and systematization of
new insights. Do anatomy, biology, culture, object relations,
affective maturation, and cognitive development account for
the psychological distinction between the sexes? Is there only
1 way of interpreting data or reality? Is there any hope or any
need for reconciliation of theories?
Postmodernism has emerged from the failure ofreduction-
ism, attempting to make sense of uncertainties. Contrary to
reductionism or eclecticism, specificity is an expression of
pluralism that is enriched by the study of differences. The
coexistence of diversities invites clinicians and scientists to
open an inter- and transdisciplinary dialogue.
Finally, gender awareness courses could be part ofmedical
training and continuing medical education. On another prac-
tical score, offending therapists should be offered not only
education but also a proper and specific treatment.
Clinical Implication
• Genderawareness coursescould be offered in medicaltraining
and continuing medicaleducation.
Limitation
• Thispaperdoesnot reviewthe cognitiveview and the linguistic
development of Freud's theory.
Acknowledgements
The author thanks Dr E Lester and Professor P Mahony for their
valuable comments.
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Resume

Objectlf : Examiner les enjeux lies au developpement sexospecifique ainsi que ses applications et repercussions
au regard de la psychiatrie dynamique.

Methode: Cet article presente I'etude des differences entre les sexes comme une reflexion ininterrompue sur les
attributs, les similarites et les differences entre les hommes et les femmes. On se penche sur un theme particulier
de la documentation abondante sur Ie sujet.
Resultats : Le developpement psychosexuel sexospecifique et l'etablissement de l'identite sont intimement lies et
determines par de multiples facteurs biospychosexuels. Le point de vue sur la feminite est examine brievement a
la lumiere des nouveaux developpements de la theorie.
Conclusions: L 'article souligne lefait que l'identite sexuelle est un outil conceptuel de plus en plus utile dans la
pratique clinique, I 'enseignement et les neurosciences.