Journal of the American Psychoanalytic Association

These reflections concern ongoing confusions in holding together the gestalt of the natal body, sex, gender, and procreation. Highlighting theoretical confusions is the shifting history of relations among the material body, the “psychoanalytic body,”:sex, and gender. Studying these confusions and collecting more data may help the field advance where a rush to theoretical foreclosure will not. Observe, for example, how commonly foreclosing are the terms “masculine” and “feminine” when automatically applied to the merely biological attributes of a sexed body. More confusions arise from theorizing gender identity using split-off images of body parts divorced from any natal referent. In a published clinical case, for instance, the role of the procreative body is characteristically ignored in gender theorizing. Apparently unspeakable horrors of the female body come with its birthing potential and may be a motive for erasure. Julia Kristeva, an exemplary writer, accepts simultaneously a sexed, procreative, and gendered layering in the mind. Her account of the “abject” can shed light on the suppressive horror in our field, which remains almost silent on the body’s procreative potential in everyday life. By contrast, even Ice Age sculptors were engaged with procreative female bodies.

Didier Anzieu’s notion of the skin-ego builds on a long psychoanalytic tradition that began with Freud’s idea that the ego is first and foremost a body ego, a projection in the psyche of the surface of the body, or, in other words, the idea that psychic phenomena are always embodied. An interface, a container for the ego, but also its origin: thus did Anzieu conceptualize the skin’s psychic function. The baby’s fantasy of having a common skin with the mother is the concrete starting point for a development that, through the prohibition on touching, leads to the experience of being a separate and individual person. Psychoanalytic work with severe mental disorders makes it necessary to investigate deficiencies in the skin-ego’s containing function before the patient’s psychic contents can be explored. In the psychoanalytic situation, the analyst’s words replace tactile contact and thereby contribute to healing injuries to the skin-ego. The clinical implications of Anzieu’s theoretical model are illustrated by examples from psychoanalyses of children and adults. The close connection between touch, psychic envelopes, and thinking opens a wider perspective on the necessity of setting limits to violence, against both nature and human beings.

In contemporary psychoanalytic writing, gender tends to be disarticulated from sexuality. While this has been a theoretically useful approach, especially as regards the critical appraisal of early traditional literature (which often assumed a facile coherence between sex, sexuality, and gender), this position too often leaves gender stripped of one of the most compelling forces in psychoanalytic theorizing, namely, its relation to the sexual. Here the diaries of Lou Sullivan (1951–1991)—a transsexual man who began writing long before considering sexual transitioning—are used to present an extended example of the intimate linkage between gender and sexuality. The diaries stand as a unique historical archive: a fairly comprehensive, prospective, first-person account of transsexuality, begun before the subject self-identified as transsexual, which documents a complex and candid subjective evolution. Situated historically during a time of enormous upheaval in both psychoanalysis and the culture at large on questions of gender and sexuality, the diaries offer an additional opportunity to consider the nexus of individual psyche and social forms.

The discourse on psychic bisexuality is explored as it unfolds in Freud’s writings, in contemporary papers by LGBTQ psychoanalysts, and in a volume of essays, Psychic Bisexuality, published in 2018 by a group of prominent French and British analysts (Perelberg 2018). The greater acceptance of nonnormative sexualities and genders is reshaping the discourse on bisexuality and gender in many corners of our profession, yet, as the Perelberg volume attests, that evolution is far from universal. A strain of unquestioned heteronormativity and cisgenderism is evident in Perelberg et al.’s description of the fundamentals of psychic life, a strain that has roots (via a certain one-sided reading of Lacan) in Freud’s unresolved mourning of his inchoate homosexual self. A more embracing vision of bisexuality would seek to “hold,” rather than enact, the grief and anxiety associated with the development of myriad diverse personal patterns.

The concept of affirmative consent presumes a subject who is fully transparent to herself and who can anticipate the precise effects of her assent. This essay proposes limit consent, a concept that offers us different ways to think about the sexual—and about the analytic encounter. Limit consent involves a more nuanced negotiation of limits and becomes possible when the subject makes herself passible (Lyotard 1988) to an other—a condition that is neither active nor passive. Processes described in depth here suggest that passibility has ties to the rousing of infantile sexuality (Freud) and to the subject’s normative perversity (Laplanche). When the psychic economy of the infantile sexual is followed to its apex, a particular kind of state is produced that I call overwhelm—a word that is used here as a noun. Overwhelm is a state of dysregulation that can be confused with, but is not the same as, repetition compulsion. Overwhelm entails risk, and under some circumstances it may open up space toward significant psychic transformations. A detailed clinical example illustrates how overwhelm may make itself known in the clinical encounter, and how it can infiltrate the transference/countertransference. Specific technical suggestions are made regarding analytic work with overwhelm.

The impact and complex nature of keeping secrets deserves greater scrutiny within psychoanalysis. While the capacity to keep a secret is a developmental achievement that furthers conscious choice and healthy boundary setting between self and others, an individual’s need for privacy must be distinguished from untoward costs of collusion and concealment. Clinical case material shows that not all secrets are unconscious or multilayered, as assumed in most of the psychoanalytic literature. Nonetheless, in these cases deleterious effects to psyche and soma took root. These patients assumed that their secret was irreparably destructive to an essential object relationship; shame, guilt, narcissistic vulnerability, unconscious identification with an injured party, and developmental deficit were other factors found to undergird this mode of pathogenic dissembling. Two clinical examples also demonstrate that embodied countertransference reactions may herald the revelation of a secret in treatment that had been hidden, but in plain view. Secrets appear to exert their profound psychological and physical effects on patient and analyst by biological mechanisms that are as yet poorly understood but are readily observed in clinical practice. Psychoanalysts who keep in conscious awareness both the adaptive value and the potential costs of maintaining the confidences of others over the course of a career are better positioned to assist their patients and themselves in rendering essential self-care.