Considerations on anatomical and psychic reality in relation to an intersexual patient.

On the basis of a clinical account of the analysis of an intersexual patient, the author discusses theories of sexual identity and psychosexuality in terms of the impact of bodily and other aspects of factual reality on psychic reality. She considers the extent to which a subject's fate is determined by anatomy and emphasises the importance of such factors as sexual assignment at birth. The fluctuations in Freud's views on female psychosexuality are examined in detail and it is pointed out that in his writings anatomy is always mediated by psychic reality. A critical review of later authors' theories of sex and gender then follows. Turning to her case history, the author describes the implications of her insistence, partly as a manifestation of countertransference disavowal, on seeing her patient as a woman despite the latter's self-presentation as a hermaphrodite. The significance of the patient's homosexuality is discussed and an account is given of her development in the analysis. Aspects of anatomy, bisexuality and identity are reviewed and the paper ends with a further consideration of the treatment of sex and gender in Freud and other authors leading to ideas on the role of the drives and the importance of the sexual element in identity.