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In recent years, a few patients with demonstrable abnormalities of their sex have increasingly puzzled me. In a series of 28 biologically intersexed patients, there have been 7 in whom a biological abnormality of sex was present but unknown to the patient, and yet the patient's gender identity was like that of a person raised in the opposite sex. We shall look at these cases for clues as to whether the sex abnormality influenced gender behavior in a biological manner or whether the observed effects were psychologically produced.
I have called the earliest formations of gender identity and those most invulnerable to the onslaughts of psychological conflict “core gender identity.” In its simplest form, this can be exemplified by the sense of identity, “I am a male” or “I am a female.” It is created, starting at birth (or before?), by several components:
The first of these is the anatomy and physiology of the external genitalia. By their “natural” appearance, the external genitalia serve as a sign to parents that the ascription of one sex rather than the other was correct. Too, by the production of sensation, the genitalia—primarily from external structures, but in females additionally and dimly from the vagina—contribute
to a part of the primitive body ego, the sense of self and the awareness of gender.
The second component, the infant-parent relationship, is made up of the parents' expectation of the child's gender identity, their own gender identity, the child's identification with both sexes, the gratifications and frustrations arising between child and parents, and many other aspects of oedipal and preoedipal development.
The third component—the one postulated in this paper—is a biological force2 which, though hidden from conscious awareness, nonetheless seems to provide some