Opposite-gender identity states in Dissociative Identity Disorder: psychodynamic insights into a subset of same-sex behavior and attractions.
Rosik, Christopher H.
Dissociative Identity Disorder (DID) is a psychological condition
wherein the individual experiences (1) the presence of two or more
distinct identities or personality states (each with its own relatively
enduring pattern of perceiving, relating to, and thinking about the
environment and self), of which (2) at least two of these identities or
personality states recurrently take control of the person's
behavior, resulting in (3) an inability to recall important personal
information that is too extensive to be explained by ordinary
forgetfulness and is (4) not explained by substance abuse or a general
medical condition (American Psychiatric Association, 1994; International
Society for the Study of Trauma and Dissociation, ISSTD, 2011).
Generally, DID is considered a trauma-driven disorder, presumably originating out of recurrent abuse commencing in early childhood. While
subjectively compelling for the patient, these alternate identities are
not separate persons but rather enactments of trauma related
intrapsychic conflict, memories, and affects (ISSTD, 2011).
Child, persecutor, and protector identity states are often
exhibited by DID sufferers. A less well noted but relatively common
alternate identity for these patients is one that takes the form of the
opposite-gender (e.g., a male identity state in a biologically female
patient). Early accounts in the literature suggested that approximately
5066% of DID patients have at least one opposite-gender identity
(MacGregor, 1996; Putnam, 1989; Ross, 1989). Putnam indicated that
child, adolescent, or adult male personality states are found in about
50% of female patients and approximately two-thirds of male patients
present with a female alternate identity. Ross found that 62.6% of a
sample of 236 DID cases evidenced a dissociated identity of the opposite
gender.
Early in the heyday of DID, ego-state theorists John and Helen
Watkins were observing opposite gender ego states and suggesting that
sexual identity needed to be studied from an ego-state perspective
(Watkins & Watkins, 1982). They reported that opposite gendered ego
states seemed to be organized around the stereotypes of maleness or
femaleness. More recently, Howell (2002) has speculated that much of
gendered behavior, and especially its pathological extremes, derives
from trauma and that specifically gendered self-states are created by
trauma. While opposite-gender identity states may be highly
stereotypical, the outward presentation of the DID patient is often more
unisex, which allows for opposite-gender identities to emerge without
creating confrontations or awkward situations in their interpersonal
world (MacGregor, 1996).
Although the early literature in this area seemed to affirm the
scientific legitimacy of studying the potential relationship between
opposite-gender identities and sexual orientation, the subsequent
evolution in the social and professional cultures as regards
homosexuality appears to have brought such inquiry to a halt. I believe
that the subject still indeed has merit, but certainly it is complex,
controversial, and ultimately beyond the scope of this paper. Instead,
using composite case material, I intend to focus more pragmatically on
the manifestation of same-sex behavior and attractions in DID patients
that arise from the activity of opposite-gender identities. By reviewing
the psychodynamics of this phenomena, I think important insights can be
gained for the therapeutic care of DID patients as well as a subset of
adult victims of childhood trauma who report same-sex attractions and
behavior.
Case Material
Gina was a 27-year-old single Christian woman who had been referred
for psychotherapy by the church where she had been helping in college
ministry. Her referral was precipitated by the discovery that she had
engaged in homosexual behavior with another woman whom she had met
during a community-wide church event. Though historically depressed and
emotionally over controlled, this impulsive act so startled Gina that
she readily consented to treatment. Over the course of several months in
therapy, it became evident that Gina was reporting symptoms that could
be explained by the activity of dissociated identity states. These
included experiencing internal ego-dystonic voices, not recognizing her
face in the mirror, not recalling some things others told her she did,
and sometimes perceiving her environment as if she was looking through
the small end of a pair of binoculars. Following a period of
psychoeducation regarding dissociative experience and the mobilization
of her limited support system, I conducted interventions aimed at
contacting potential alternate identities. This confirmed a DID
diagnosis.
One of the dissociated personality states, who identified himself
as "Alex," took responsibility for the homosexual behavior. As
Gina's dissociated trauma experience began to be pieced together
through the accounts shared by her alternate identities, it became
evident that she was reporting a series of sexual molestations beginning
in childhood, first by her stepfather and sometime later by an uncle.
While caution should always be taken not to assume the veridicality of
reported abuse memories in DID patients, memories of ordinary childhood
abuse among DID patients have been highly corroborated (75-90%).
Memories of ritual abuse are rarely corroborated (020%) and are not
likely to be literal, historical events (Dalenberg, 2006; Lewis, Yeager,
Swica, Pincus, & Laws, 1997; Kluft, 1995; Rosik, 2003). Gina
reported that neither of her two younger brothers had experienced
similar sexual abuse by her stepfather, and Alex indicated he had come
to make sure that Gina would receive the same reprieve from further
sexual trauma.
As Gina grew up, Alex reported becoming more sexually interested in
girls as "that's what guys do." Gina acknowledged in
therapy that she
had struggled, sometimes quite intensely, with sexual attractions to
some of the women in her history and had resisted acting on these
attractions in large degree because of her religious values. However,
she also recalled that a few of her past female friends had abruptly
terminated their friendships, citing behavior from Gina which they felt
to be overtly sexual in nature. Gina was baffled by these accusations
and could not imagine herself having engaged in such conduct.
As trust was built with the alternate identities, Alex confessed
that he had pursued these relationships but found "that prude"
Gina often got in his way. Even more frustrating to Alex was that on
those few occasions when he was able to assume control of the body and
initiate sexual overtures, Gina's female friends were "so
religiously hung up about sex" that they refused to respond in
kind. My treatment did not involve directly challenging Alex's
views about same-sex behavior; indeed, Alex did not even view his
activity as being homosexual in nature and such an approach would have
likely destroyed our alliance. Gina's sexual behavior in general
was not a specific focus of her therapy. Instead, my treatment involved
interventions common to DID. As regards Alex, his fundamental, trauma
driven cognitive distortions needed to be challenged, including his
belief in having a separate body from Gina's and his need to be
oriented to the present where further trauma was no longer an immanent threat. Alex began to question his own dissociative understanding of
himself and the outside world. The facilitation of communication among
Gina's alternate identities further eroded the dissociative
barriers and provided a greater context for Alex to empathically
understand the nature of the trauma they had experienced, eventually
leading to significant grief work that included Alex's deeply
hidden feelings of failure for being unable to prevent some of
Gina's abuse. A growing sense of Christian-oriented spirituality
within Gina's system of alternate identities also gave momentum to
the therapeutic process, and this was instrumental to relieving
Alex's feelings of failure and guilt.
In the end, as Gina listened to her dissociated identities and
gained a more coherent sense of self, Alex willingly integrated with
Gina's increasingly united consciousness. Interestingly, Gina
reported that her experience of same-sex attractions and conflicts were
greatly reduced, though she sometimes noticed them temporarily during
particularly stressful circumstances in her life. This could be
interpreted as a brief reactivation of her formerly dissociated Alex ego
state, but not to the point of a renewed dissociative split. As is
typical for DID treatment, integration of the dissociated personality
states marked the beginning of Gina learning to live without
dissociative coping mechanisms and having to develop more adaptive
coping skills. The treatment needs related to Alex would not be complete
without assisting Gina post-integration to develop greater skill and
comfort in her social relations (particularly with men), a task which
took significant time to accomplish despite her great desire to achieve
a level of heterosexual functioning that was satisfying to her.
Psychodynamic Considerations with Opposite-Gender Identities
Understanding the psychodynamic functions of opposite-gender
identities such as Alex can aid therapists in the treatment of complex
trauma in general and some forms of unwanted same-sex behavior in
particular. Ross (2002) suggested that opposite-gender identity states
can be based on trauma driven reaction formation to a primary
heterosexual identity. They may often be defensive adaptations to a
same-sex or opposite-sex abuser and can be active in homosexual or
heterosexual behavior, leading to great confusion about sexuality
(Putnam, 1989). The psychodynamics of these alternate identities appears
to be somewhat different for women and men DID patients, which justifies
the separate examinations below.
Male identities in female patients.
The literature on opposite-gender identities in female DID patients
has reported a number of psychodynamically compelling reasons for their
formation. These reasons are not necessarily mutually exclusive and more
than one may be relevant to a single identity state or be portioned
among different states within the same patient.
Protecting the physical and psychological integrity of the self.
Gina's case highlights the function of male identities (Alex)
serving as a kind of bodyguard to protect the patient from the
continuation of trauma. In such cases, the dynamic origin of these
differently gendered alternate identities have much more to do with
preserving a sense of strength and safety (real or imagined) than they
do with anything sexual. Such identities can present quite masculine in
their appearance, speech, and behavior (Putnam, 1989; Ross, 1989). The
dominance of a male alternate identity may also result in the female DID
patient assuming an apparent lesbian role (Watkins & Watkins, 1982).
Alex's presence was clearly established in a psychic attempt to
protect Gina from the reality of her powerlessness in the face of sexual
abuse. By creating a part that identified as male, she was able to
dis-identify with the victimized and vulnerable reality of her female
self, and in this way achieve some degree of internal psychological
mastery over her abuse.
Persecuting/Identifying with the perpetrator.
Another method of dynamically trying to undo the childhood trauma
is by creating a male alternate identity that persecutes the host
personality state and/or victimizes other women (Howell, 2002; Ross,
2002). Such male identities enable DID patients to shift from the role
of victim to that of a perpetrator and in so doing gain a psychological
sense of control and mastery over their potentially self-destroying
traumatic circumstances. Homosexually oriented female alternate
identities in female patients may also sexually victimize women, but in
this case the assumption of the perpetrator role may also serve to
enable the patient to avoid the intense fear of sexual contact with men.
Avoiding the opposite sex. Ross (2002) observed that homosexual
male alternate identities in female DID patients permit sexual intimacy
and good heterosexual functioning with men while dissociating the fear
of intimacy and sexual conflict often linked to the identity of the
female victim of male abusers. Such an identity may embody the
homosexual adaptation of the patient and serve as a denial of her
heterosexual drive (Ross, 1989). This psychological adaptation
constitutes a reaction formation to the trauma driven fear and phobia of
men and may constitute a form of secondary lesbianism (MacGregor, 1996;
Ross, 1989). Alex appeared to have developed this function subsequent to
Gina's entrance into puberty.
Tolerating unacceptable sexual contact.
Male alternate identities in female DID patients can also provide a
mechanism for achieving healthier sexual intimacy with women while
avoiding the fear and conflict linked to the identity of the female
abuse victim (Ross, 2002). They may also serve the defensive function of
shielding the patient from conflict regarding her lesbian sexual
behavior, which is common among religiously conservative patients. This
dissociative strategy solves the problem of how to have sex with a
same-sex partner while maintaining a heterosexual self-identity (Ross,
1989). A homosexual-oriented female alternate identity can also
accomplish this task.
Procuring intimacy and affection. Since the female DID patient
sexually abused by male perpetrators typically have great difficulty in
their sexual relationships with men, male alternate identities who are
sexually attracted to women may also serve as a primary means of
obtaining physical intimacy, affection, and warmth (Ross, 1989). Here
sex is a secondary issue in their sexual behavior. In female patients
where value conflicts regarding homosexual behavior are not present,
homosexually-oriented female identities may be the more common means of
gaining comfort.
Performing "masculine" tasks. Putnam (1989) noted that
male alternate identities in female DID patients sometimes serve as
mechanics or otherwise operate machinery. This function is not specified
in the rest of the literature. However, it is likely that some male
identities are created to assist in tasks that are culturally masculine,
such as mechanical operations or sports activities.
Female identities in male patients
There is much less literature devoted to the presence of female
identities in male patients. Only Putnam (1989) addressed this topic in
some detail, suggesting that such female identities usually come in the
form of an older "good mother" figure. This identity functions
to provide comfort and attempts to soften what is often angry and
destructive behavior of male DID sufferers. While Putnam asserted that
male DID patients are somewhat more likely than female patients to have
opposite-gender identities, this statement has not been repeated or
confirmed in the subsequent literature.
Transgenderism and transsexualism
Worth mentioning in the context of opposite-gender identities are
their potential involvement in certain cases of transgender and (should
sex-change surgery be pursued) transsexual identities. Putnam (1989)
noted that many male DID patients present with host states that are
outwardly effeminate and often homosexual in orientation. He further
observed that in cases where the opposite-gender identity perceives the
body's actual anatomical sex, there may be attempts to change it,
including sex-change surgeries. Ross (1989) also suggested that the
phenomenon of transexualism may be dissociative in nature. He cited the
example of having assessed a man for sex-change surgery only to discover
that a female identity within the undiagnosed DID patient was the
driving force behind the pursuit of the operation. Rivera (2002) also
mentioned cases of undiagnosed DID in transexuals that resulted in
post-surgical psychological decompensation.
The World Professional Association for Transgender Health's
7th Edition of their Standards of Care for the Health of Transsexual,
Transgender, and Gender Nonconforming People (WPATH, 2011), make clear
that these conditions should not be reduced to simple dissociative
explanations. However, the Standards of Care do explicitly refer to DID
as one co-occurring condition for which gender nonconforming clients
should be evaluated, particularly prior to sexual reassignment surgery
(SRS). If confirmed, the Standards of Care assert that DID must be
treated before commencement of SRS. This caution appears well supported
beyond the anecdotal case evidence noted above.
One study of 64 high functioning transexuals found 10% of the
sample scoring above 30 in the Dissociative Experiences Scale, which
suggests the presence of a dissociative disorder (Walling, Goodwin,
& Cole, 1998). Since the mid-1980s, rates of regret among
individuals who pursue sexual reassignment surgery (SRS) have varied
from 10% to 30% (Olsson & Moller, 2006). Recent reports suggest that
while SRS often improves sexual functioning and gender dysphoria among
post-operative transsexuals, it may not remedy high rates of morbidity
and mortality among these individuals (Dhejne, Lichtenstein, Boman,
Johansson, Langstrom, & Landen, 2011; Klein & Gorzalka, 2009).
Prior longitudinal SRS outcome studies may not have had follow up
periods of sufficient duration (at least a decade) to detect the
persistence of such elevated risks.
Implications for Treatment
These apparent psychodynamic considerations may be especially
important in light of the fact that relevant practice guidelines provide
little direction in understanding or untangling the dissociation and
same-sex attraction/behavior interaction. Although the WPATH Standards
of Care (2011) explicitly mention DID as a possible co-occurring
condition with transgenderism and transsexualism, the Guidelines for
Psychological Practice with Lesbian, Gay, and Bisexual Clients make no
mention of dissociation or dissociative disorders (American
Psychological Association, 2011). In fact, these guidelines make no
mention of sexual abuse, only one mention of physical abuse, and only
mention trauma in the context of discussing minority stress. Similarly,
the Guidelines for Treating Dissociative Identity Disorder in Adults
(ISSTD, 2011) fail to address the topic of sexual orientation. The
reasons for such contrasts between and omissions within these
professional guidelines are not clear; nevertheless, clinicians faced
with patients such as Gina need to be familiar with these guidelines as
well as the controversies involving sexual orientation change (American
Psychological Association, 2009; Jones, Rosik, Williams, & Byrd,
2010).
Thus, while somewhat dated, the literature germane to DID and
same-sex attractions and behaviors cannot be easily dismissed. The
psychodynamics of opposite-gender identities in DID provides clinicians
with some beneficial insights for psychotherapeutic treatment,
particularly where unwanted same-sex attractions and behavior have been
reported in traumatized patients who evidence a significant degree of
dissociation. Some of these are described below in no particular order
of importance.
Sexual behavior as a secondary issue
Dissociative and traumatized patients may be very focused on the
unacceptability of their same-sex behavior and attractions, especially
if they come from conservatively religious backgrounds. While it may be
tempting for therapists who are Christian to place an initial focus
primarily on the patient's sexual behavior, this would be a
mistake. The psychodynamics of opposite-gender identities illuminates
the reality that in these cases same-sex sexual behavior is often formed
as a psychological adaptation to cope with trauma. Therefore, while the
therapist sometimes will need to assist the patient in establishing
boundaries on sexual behavior, the goal of effective treatment cannot
simply be behavioral management. Unless the underlying, trauma-driven
dissociative distortions in cognitions and self-perception are
addressed, the psychological coping mechanisms that may give rise to the
unwanted same-sex behavior and attractions are likely to continue to
perpetuate them. The goal is to dissolve the dissociative barriers
between identities through the processing of traumatic material and
correction of related cognitive distortions. Ross (1989) observed that
opposite-gender identities can be integrated with no disturbing effect
on the patient's primary gender identity.
Trust is a must
It is impossible to stress how important the establishment of
safety and trust is in the treatment of DID related unwanted same-sex
attractions and behavior. This insight is related to the previous one in
that religious moralizing by the therapist regarding same-sex behavior
will only serve to hinder the patient's ability to address it by
reinforcing the defensive functions of the opposite-gender and other
identities. The conservative Christian patient, in particular, is quite
likely to have already internalized condemnatory messages regarding
same-sex behavior, so that an early treatment goal is to facilitate the
development of a strong alliance by providing a safe, nonjudgmental environment. Same-sex behaviors and attractions can be therapeutically
examined more from a position of functional curiosity than moral
evaluation. Furthermore, in the treatment of DID, the therapist has to
establish trust with all of the identities, and to favor one may raise
the ire of others (MacGregor, 1996).
Thus, a host identity may have rigid convictions against same-sex
behavior, but an opposite-gender identity may not even perceive the
sexual behavior in this manner and consider the therapist's strong
affirmation of the host's perspective as a threatening collusion.
Even in non-DID patients with childhood trauma, it will benefit the
therapeutic relationship if therapists keep in mind that what they say
about the patient's same-sex behavior may well be received by ego
states who have dynamic functions similar to what has been noted above.
The art of therapy in providing DID patients with a safe and healing
environment lies in the therapist's ability to walk that fine line
between the unproductive indulging of identities in their perceptual
distortions and the unintended reinforcement of dissociative defenses in
the provision of reality-based boundaries.
Griefwork
Opposite-gender identities, as is the case for most other
identities in DID, are trauma-driven. Once safety and trust have been
reasonably established within the therapeutic relationship, the gradual
work of diminishing dissociative barriers and promoting integration of
identities begins. As dissociation gives way to re-association, the
confronting and processing of traumatic material typically brings
patients face-to-face with the unvarnished reality of their abusive
childhood experiences. This integrative task is facilitated and brought
to completion by ongoing griefwork (Howell, 2002). For example, by
becoming aware of the traumatic material of other identities and the
perceptual incongruity of his male gender, Alex came to recognize his
protective function and began (along with other identities) grieving the
harsh reality that Gina had been left utterly unprotected by her mother
and other guardians.
Final Observations
MacGregor (1996) astutely noted that, "Perhaps more than any
other disorder, MPD [multiple personality disorder, now termed DID]
suggests the plausibility of psychoanalytic concepts" (p. 389).
Because I believe this to be absolutely accurate, I have taken somewhat
of a risk by examining same-sex attractions and behavior through the
lens of DID and opposite-gender alternate identities. It is evident from
this analysis that there is a dearth of literature addressing this topic
and that what literature there is has evolved in ways that mirror the
cultural shifts regarding the psychological status of homosexuality.
That is, the earlier analyses seem more open to the application of a
dissociative trauma model in understanding the origins of some same-sex
behavior and attractions. By contrast, more recent discussions appear to
discount their potential etiological significance. Without arriving at
any peremptory determination on this subject, I want to close by making
two observations that I believe will ensure a scientifically responsible
treatment of the topic.
First, responsible theorizing about the role of opposite-gender
identities in same-sex behavior and attraction has to acknowledge that
such extreme dissociative dynamics are likely to be involved in only a
relatively small percentage of individuals with such experiences. Case
examples such as that of Gina have a primarily heuristic value for the
development of hypotheses and cannot be assumed applicable to other
cases in the absence of further scientific evidence. Insights gleaned
from DID sufferers may well have a broader relevance to non-DID patients
who report childhood trauma and same-sex behavior, but even then one has
to be careful not to over generalize their relevance in understanding
the origins of behavior associated with minority sexual orientation. I
am familiar with cases of DID where the post-integration sexual
orientation identified as homosexual, so it should not be assumed that
the healing of trauma necessarily results in a heterosexual adjustment.
That being said, however, the other danger to avoid is to deny
altogether the psychodynamic implications of opposite-gender identities
in comprehending trauma-driven contributions to the genesis of some
cases of same-sex behavior and attractions. The more recent writing on
this subject appears to discount such possibilities as a perquisite for
being scientifically credible (Howell, 2002; Rivera, 2002). From my
perspective, however, a scientifically honest curiosity into this
phenomenon that is not constrained by sociopolitical considerations
would be eager to undertake research and theorizing about it. Yet a
fairly pervasive silence on this intriguing topic currently exists
within the dissociative disorders and human sexuality fields. Perhaps
this is occurring out of an understandable desire to not add to the
stigmatization of sexual minorities by linking childhood abuse to the
development of even some instances of homosexuality. If this is
accurate, then it must at least be recognized that the resulting
political climate surrounding the social sciences may be hindering the
profession's ability to alleviate the suffering of some individuals
who present with histories of trauma and unwanted same-sex attractions
and behavior. I sincerely hope the future will show that preserving
human dignity and relieving human suffering need not be mutually
exclusive aims in addressing the intersection of dissociation and
same-sex experiences.
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Siang-Yang Tan & Timothy K. Wong
Fuller Theological Seminary
Please address all correspondence to Siang-Yang Tan, Ph.D.,
Professor of Psychology, Graduate School of Psychology, Fuller
Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101.
Christopher H. Rosik, Ph.D., is a psychologist and Director of
Research at the Link Care Center in Fresno, California. He is also a
member of the clinical faculty at Fresno Pacific University. His areas
of interest include missionary and pastoral care, dissociative
disorders, human sexuality, and the philosophy of social science.