The Wish for a Sex Change

Dear Mr. Tuckett,

It was very exciting to see an article on transsexualism in the International Journal because this topic goes to the heart of some of our assumptions in psychoanalytic theory of identity, self, and change. There has not been a lot of reports about these types of sexual problems in our literature nor any reports of patients undergoing full psychoanalytic treatment before beginning hormone use or other physical treatments. The difficulty of getting these people into treatment is well discussed by Agnes Oppenheimer in her article, 'The Wish for a Sex Change: A Challenge to Psychoanalysis?' 1991, 72: 221–231.

Unfortunately neither of the two case reports in her paper were documented to be in full psychoanalytic treatment. The frequency of sessions, length of treatment, and the process of analysis (which includes the evolution and use of the transference relationship) was not stated in the first case and the second case is reported as coming once a week. From the data that is reported the author inferred that the patients defensively denied their 'real' sexual identity and were not open to interpretive efforts to address this resistance. She quickly dismisses Robert Stoller's long term research and conclusions on transsexualism as merely complying with the patient's wishes and therefore not helpful to analytic treatment of them. Oppenheimer states that she found an empathic attunement most helpful in getting analytic data from these patients but her interpretations and theoretical formulations indicated that she understood the problem only in an instinctual drive and defence model.

My impression from the article is that our theories still prevent us from deeper understanding of what our patients are experiencing. Why did Oppenheimer not have these people in full psychoanalytic therapy at four or five times per week where a deep experience of their transference relationship could occur? Only in this way will we be able to use our psychoanalytic