The initial focus of the COPE Study Group on the Female Body, integrating biological and psychoanalytic concepts, has developed into a more clinical project. We are interested in those individuals for whom the body serves as a way of experiencing and expressing memories, affects, and relationships. We have been identifying, describing and working to understand patients for whom this is central. The body is often absent from clinical descriptions that focus on the psychic reality and do not include somatic reality. We are considering the whole body, not specifically the genitals.
A broader concept that has evolved from our discussions is the concept of the “somatic self” as a characteristic that captures the woman's sense of herself and her body. We are interested in the role a woman's body plays in her self concept. The shape, size and functioning of the body also contribute to the psychic reality. There is a reciprocal relationship between the effects of one's self concept on bodily functioning and the effect of the body's functioning on the sense of the self. For example, a self concept as strong, powerful or being identified with a particular parent can affect posture—being “straight,” holding oneself tall, or being stooped or crouched. Size, athletic ability, as well as being seen as beautiful, contribute to self-esteem. Particular characteristics also have meaning, such as eye and hair color.
The representation of the body, the way one perceives oneself, is also determined by the sensory processes of perception, the visual, auditory and tactile sensations, and by memories, residues of one's experiences and the emotions that accompany the memories. So concepts such as “ugly” and “strong” are ideas, part of the mind, and not only express ideas about the body but also involve the neural circuitry that has to do with perception, memory and experiences. Recognizing the neural circuitry provides one level of integration of the biological and psychoanalytic.
“Biological” contains many elements, including circulatory, hormonal, neurological and anatomical. Hormonal interactions also influence the way we feel, and feelings influence hormonal activity. In the group we have also considered biological and psychological aspects of important female body experiences, such as pregnancy, menstruation, menopause, breast development and breast augmentation. We have discussed the ways in which depression affects female body functions. Infertility is an example of a situation where the fact that the body is not functioning “as it should” has profound effects on self-esteem. It can create feelings of helplessness and failure, being unable to fulfill a critical realization of female gender identity. Current knowledge attributes about one-third of infertility problems to male conditions, another third to female conditions, and one-third are either combined or unknown. However, a woman may feel responsible even if the problem is not primarily hers, since being able to reproduce is such an important part of a woman's traditional and historical role whether or not she actually wants children at a particular time.
We have had a number of presentations of patients for whom somatic issues were prominent. One patient had concrete fantasies about her analyst's body, particularly her breasts. These involved detailed daily observations of the analyst's body and represented her wishes for closeness by fantasies of being inside her analyst's body. She also felt that closeness was more possible because as women they shared the same bodily configuration and sensations. At times she had the fantasy that she and her mother were in the same body.
Another patient recalled memories of sexual abuse by remembering physical sensations, which she then identified as being the prickly mustache of the abuser. Another patient did not at first understand her reluctance to brush her teeth, until it became clear that this was associated with memories of oral sex.
Many women change the shape of their bodies to deal with sexual feelings or experiences. Becoming fat avoids presenting oneself as sexual or having sexual feelings. One patient literally needed to create layers of fat so she could begin to talk about a long and not openly discussed history of sexual abuse. Body sensations contained the memories. Body feelings, such as having legs that were heavy enough that they were touching served defensively.
Another patient, a successful professional woman who was seen for many years, used her body symptoms such as nausea to express affect, still needing the analyst's help to recognize anger and panic. These patients are examples of people who have important somatic components in their clinical presentation.
We have considered the effects of acute and chronic trauma. There is evidence that there are brain changes affecting sexual response in individuals who have experienced chronic sexual abuse.
We are exploring ways of fulfilling the educational mission of COPE. We thought about developing a curriculum and a bibliography for teaching about the actual physical body in clinical work Our current plan is to describe several cases, including some that have been presented, accompanied by a bibliography related to the particular problem of each patient. We would like to describe all aspects of the patient, psychological and somatic, and aim to integrate these into one coherent formulation.
Malkah Notman, M.D., graduate of Boston University School of Medicine, is clinical professor in psychiatry, Harvard Medical School; faculty at Cambridge Health Alliance; faculty and training and supervising psychoanalyst, Boston Psychoanalytic Society and Institute; and in private practice, Brookline, Massachusetts.