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REVIEW PAPER

Psychoanalytic Contributions to the Study of Gender Issues

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 of thinking about male
and female attributes, similarities, and differences. The paper reviews a specific thematic area of the
extensive literature on the subject.
Results: Gendered psychosexual development and identity construction are intertwined and determined by
multibiopsychosocial factors. Freuds 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;44:7276)
Key Words: gender, dynamic psychiatry, psychoanalysis, femininity, postmodernism
Some events of universal interest leading to new theoretical developments usually have triggered
controversies and deep internal malaise. Indeed, Copernicuss heliocentrism (1473) was at the origin of the
scientific revolution of the 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 humankinds alienation in relation to the economical
structure of society. A century ago, Freuds ideas were assailed from every quarter when he founded
psychoanalysis as a theory and as a method of treatment for neuroses.
Psychosexual development, psychic determinism, and the dynamic unconscious are evidence of the
subjection of reason to impulses. Like a key unlocking the unconscious, contemporary 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 in the treatment of the mentally disordered.
However, at that time, therapeutic choices were scarce. Branching out from psychoanalysis, 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 find effective strategies to help numerous
patients.
Psychoanalysis and other mentalistic approaches have become 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 remedicalization 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 medication prescribed when it is needed. Likewise, to enhance the
therapeutic effects of pharmacologic and community approaches, dynamic thinking again finds a place in the
management of clinical impasses and refractory cases and in the treatment of the difficult patient (Axis II
diagnoses), among others. The study of resistance and defence shows how the patient deals with conflicts,
protects secrets, and avoids unpleasant feelings that hinder treatment. Hence, psychopathology 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 of the 20th century, with the advent of postmodernism 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, religion, education, and women-related issues on campus. On a relative score, during

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the 6th annual National Survey of Canadian Doctors (5), a gender-based difference in opinion regarding the
prescription of psychotropic 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, Freuds 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 Freuds 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 of women
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 distinguished between sexual
and genital concepts and referred to the castration complex as a psychic organizer.
The validity of many of Freuds ideas were disputed since they did not reflect womens experiences. During
the 1920s and 1930s, some of Freuds contemporaries participated in the first debate on femininity to focus
on penis envy and subsequently motherhood (8), thus furthering the psychoanalytic conceptualization on
femininity. For Abraham (9), Klein (10,11), and other followers of the English school, psychosexual
receptiveness in a girl was associated with a greater capacity for interiorization of her parents. In addition,
Jones (12), Horney (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 of mental
development. The centrality of the preoedipal maternal determinants in pathology and treatment was well
emphasized by Winnicott (15,16). He is known for many important concepts, including the good enough
mother, the transitional object and space, illusionment and disillusionment phenomena, 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 of the 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 preponderant 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 of
gender role and gender role as the public expression of gender identity (18). Friedman enumerated different
pathological categories related to gender identity disturbances in childhood (22).
During the 1970s and 1980s, the second debate on femininity centred on the issues of gender identity with a
rapprochement of psychoanalysis, biology, and sociology (2325). Scientists such as Keller agree on an
autonomous line of development in women and on the centrality of the motherdaughter relationship as a
determinant of femininity (26). Chodorow explains that, whereas initial oneness with the mother is longlasting 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 of
gender identity (28). Person studied the role of culture in fantasy formation (29); she describes female and
male fantasies related to cultural stereotypes of male and female sexuality. In the context of defensive
dynamics, Begoin referred to Freuds refusal of femininity 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 personality. 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
acknowledgement of the fathers presence as an intrapsychical dimension of separation and reality.
Gender Differences in Male and Female Psychological Development
In addition to genetics and embryology, neuroendocrinology 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 1819) of brain differentiation and
organization. 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 parental attitudes and fantasies are important in defining
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 motherchild interactions (34,35). Early affectomotor responses and sensorimotor patterns seem to

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contribute to the establishment of gender differences. Female neonates show earlier neurologic maturity (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 separation. Stoller affirms that, for both boys and girls, there is an early stage of fusion with
the mother, a stage of protofemininity or sense of femaleness in both sexes. The girls sense of oneness
with the mother is a conflict-free aspect that helps her to establish a sense of femaleness. Conversely, the
boys 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 muscular activities and rough play and generally need a greater assertive
experience of the ego boundaries. Tyson defines a first stage during which developmental tasks impact the
narcissistic consolidation of the body image (39). The availability 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-identifying from the mother (40). The second stage, defined 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, samegender dyadic issues (the preoedipal attachments and deidealization of the 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 of gender identity,
gender role, and sexual partner orientation.
Thus, the continuous and never-ending process of progression 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 boundaries, and identification of similarities and
distinctions between 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
disorders, alcohol-related disorders, antisocial personality disorders, 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 disorders; 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. Gender 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
psychopharmacological investigations in which the population tested is predominantly 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 disturbances are virtually
ubiquitous. They can be found in neuroses and in many personality disorders.
Sexual violations continue to occur despite well-publicized clinical and ethical prohibitions. Gartrell and others
reported that, in the case of mental 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 psychopathic 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 frequent in men, it is the most frequent
type in female therapist transgressors as well.
Gender Awareness and Theoretical Contributions to Psychodynamic 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 Initial 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 transference in a female patient (48). Focusing
on gender and therapeutic boundaries, Gabbard and Lester affirm that gender differences and interpersonal
boundaries (female permeability versus male thickening) influence the treatment process and that women,

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more frequently than men, develop erotized transference onto a female or male analyst (49). Lester explains
further how in the femalefemale dyad the excessive connectedness of the therapist (a trained
psychodynamic therapist) can trigger a therapeutic impasse (50,51). In general, 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 detachment or oedipalization of the dyadic transference. Data concerning
paternal transference onto a female therapist is somewhat controversial. Some authors believe that male
patients 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 masculine 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 viewpoint, Notman and others
mentioned several works on the issues of hormones, genetics, neurotransmission, hemispheric specialization,
infant research, and potential for connectedness to the caregiver (52). Anthropological and sociocultural
studies are also worth mentioning, particularly their consensual 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 childrens 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 constructed 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 of reductionism, 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 of medical training and continuing medical education. On
another practical score, offending therapists should be offered not only education but also a proper and
specific treatment.
Clinical Implication
Gender awareness courses could be offered in medical training and continuing medical education.
Limitation
This paper does not review the cognitive view and the linguistic development of Freuds theory.
Acknowledgements
The author thanks Dr E Lester and Professor P Mahony for their valuable comments.
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Rsum
Objectif : Examiner les enjeux lis la question du genre ainsi que ses applications et rpercussions au
regard de la psychiatrie dynamique.
Mthode : Le sujet du genre est conceptualis, dans cet article, comme une construction mentale qui
sexprime par des attributs, similarits et diffrences de genre masculin et fminin.
Rsultats : Le dveloppement psychosexuel et didentit de genre sont intimement lis et dtermins par de
multiples facteurs biopsychosociaux. Le point de vue freudien sur la fminit est examin brivement la
lumire des nouveaux dveloppements thoriques.
Conclusions : Larticle souligne le fait que le sujet du genre devient un outil conceptuel de plus en plus utile
dans la pratique clinique, lenseignement et les neurosciences.

Manuscript received March 1998, revised, and accepted June 1998.

A more detailed version of the original manuscript was presented for internal use, as a training requirement,
to the Canadian Psychoanalytic Institute, Quebec English Branch, in May 1997.
1

Medical Lecturer, affiliated with the University of Ottawa, Ottawa, Ontario.

Address for correspondence: Dr NB Barbieri, 117 Murray Street, Suite 201, Ottawa, ON K1N 5M5
email: barbieri@istar.ca
Can J Psychiatry, Vol 44, February 1999