To make a male: what does it take?1

This article presents a case study of a year of psychotherapeutic work by a female and male therapist with a 14-year-old boy born with ambiguous genitalia. His mother was also present in the sessions at the request of Zak. We describe the early trauma surrounding Zak's birth and the subsequent desertion of a violent father. We present the catalogue of medical interventions he received to re-construct his genitals. Now at the age of 14 years Zak is entering into a chemically induced puberty. His mother had a version of an internal couple at war, where the male was viewed as useless and with suspicion. This view served to distort her capacity to bear Zak's condition and dovetailed with his phantasy of a monstrously violent and destructive male. Thus the artificial shove into manhood for Zak was filled with terror. The induced puberty was felt more like an attack and he acted out through resistance to intervention and non-compliance. This organisation created in him a state of thoughtlessness and despair, which we propose parades itself as a ‘secondary handicap’ (Sinason, Mental Handicap and the Human Condition, Free Association, London, 1992). Our joint work as a couple with Zak and his mother stood in opposition to their internal structures and provided an experience of a different kind of coupling: an opportunity to observe a cooperatively working couple who helped give words to the anxieties they brought. We trace Zak's attachment to and internalisation of a thinking couple, which paralleled both his ability to become more expressive and a reduction in acting out his aggression. The work aimed to promote in Zak a level of emotional development that was commensurate with his physical development. The construction of genitals and a lifetime of testosterone injections alone will not allow Zak to grow into the man he can be. We will attempt to explore the basis of these structures to demonstrate that the work provided the opportunity for Zak to reflect upon and express his terror, and to turn to other people to seek support, help and advice.