The Wish for a Sex Change

Dear Sir,

I thank Dr Carder for his comments which give me the opportunity to clarify my positions and thoughts.

First, I would like to stress that I fully acknowledge Dr Stoller's contributions, even if I disagree on some points. He was not so much interested in transsexualism per se, but in the formation of core gender identity. Recognizing that most adult transsexuals do not fit the feminine boy syndrome he identified, he made a distinction between primary and secondary transsexualism.

Regarding primary feminine identity, Lothstein has observed boys with the same type of feminine behaviour dictated by their hatred of their male genitals. It is not because Stoller did not see any conflict that there is none: unconscious conflict is not a matter of observation. My adult patients say that they have no conflict, except with external reality, but the material demonstrates the contrary. How could a boy with an absent father, used by his mother for her own narcissistic purposes, not develop a narcissistic failure? He is not recognized for what he is. How would such a wound not create conflict? I do not think that anything but a false self can be constructed; a real gender self can only be built on body image and identifications.

I agree that my material is not fully psychoanalytical, but it shows that transsexuals are seeking narcissistic acknowledgment. Their acting seems to me to be a solution to wounds and conflicts. They overcome a deep trauma by drawing upon narcissistic sustenance from their transformation.

I have not been able, up until now, to convince transsexuals to undergo psychoanalysis; that may be part of their problem. They derive gratification that they are not ready to relinquish in favour of treatment.

This leads me to my last point. I do not see empathic attunement as contradictory to a framework of drive and defence. Empathy is not sharing the patient's convictions. Different parts of the self have to be heard. Even if I recognize the defi