Emergence and handling of gender in the clinic. From substance to object (2014)

Emergence and handling of “gender” in the clinic, from substance to object

Cliniques Méditerranéennes, 2014/90, p. 139-152.

Gender is not a psychoanalytic notion, and its definition within our epistemological field remains difficult. Nevertheless, we cannot pretend, today, to be able to overlook its effects, its presence, or the questions it raises. New figures of gender have been present in the current state of sexuality for more than thirty years; society is challenged by it in its laws ¹, psychoanalysis itself is called into question by gender ², in its foundations, its practice, and its experience. The clinician and the analyst therefore have a use for gender in the clinic, whether they want to or not, whether they realize it or not. Thus, unless we risk playing Monsieur Jourdain and remaining in ignorance of our practices, we must open the following questions: what do we do with gender? What do we know about it? It is a matter of clarifying the interests of gender in the psychoanalytic clinic, and the epistemological stakes that this notion involves. It then, of course, concerns our technique and our therapeutic perspectives. With Marc, a 22-year-old trans man, we specifically encountered this question of whether gender ³ as

an object could be used as an object of addiction, or as an addictive process. A process of objectalization, of manufacturing the object, which allowed us to consider the path from substance to object, when the body becomes imaginary and constitutes itself, from the flesh to its specular and non-specular grasp. The transference then welcomes gestations and constructions tending to support an arrangement of sexuation for which gender becomes a vector.

substAntified gender

Marc ⁴ is 22 years old when we meet for the first time, during a consultation at my office. His initial request, as expressed, concerns his transition journey, for which he wishes to have a space to think and progress in this “sexual journey.” Since I am not a psychiatrist, this “psy” follow-up cannot be integrated into the framework of the mandatory follow-up required by the official protocol in France for this type of support, when hormonal treatment is desired, followed by surgery ⁵. But this is not Marc’s wish, as he is already taking hormones on the black market. And above all, he does not want any surgery, so he has no “interest” in joining an official transition follow-up. Marc works; he holds a job in the commercial sector, he is a salesman. He lives alone in Paris, where he grew up. His income allows him to live comfortably in his view, to ensure the progress of his “sexual journey” project, and to pay for “psy” sessions. Marc is a trans boy, heterosexual, who likes girls, women, or trans-feminine people, as he specified the scope of his heterosexuality to me ⁶. He

had never seen a “psy” before meeting me. How did he choose me? Because one of his friends, who comes to see me, gave him my address and contact details. We begin the follow-up, starting with one interview per week.

Very quickly, the question of hormones takes on importance in Marc’s discourse. He has just started this “treatment,” which he names as such although he does not benefit from a medical prescription or financial coverage for said treatment. His supply is regular, similar to the methods used by some athletes to obtain testosterone. With medical follow-up and a proper prescription, Marc could benefit from a Testogel^{® 7} treatment, an ointment. For various reasons, he obtains testosterone for intramuscular injection, which he applies himself, after taking some advice from a nurse friend. Marc is in good health, without any particular infection or drug dependency. His sleep is good, and his appetite “does not lag behind,” as he says. He smokes tobacco irregularly and consumes alcohol occasionally, and in a festive manner. He has never injected drugs, has sometimes snorted cocaine and drunk GHB 8 during sexual intercourse. While the self-administered nature of the treatment seemed obvious to him at first, and easily livable in his self-representation, time passes and, now, this practice looks more and more like a drug-addicted use that displeases him. The initial psychological effects of testosterone are no longer increasing; Marc has generally become accustomed to the new masculine characteristics (increased libido, greater impulsivity). On the other hand, bodily transformations are gradually gaining ground, but are progressive (body hair, voice, musculature), and regularly require psychological adjustment: modification of the body image, new designation of certain parts of the body (legs become thighs, for example). In this context, Marc accepts my recommendation to engage in ordinary medical follow-up for the hormonal treatment, and therefore to stop his solitary experimentation. This seems possible to him, whereas at the beginning of his transition journey, he claimed a more libertarian initiative. The doctor accepts the follow-up and prescribes the replacement treatments to Marc, who applies the ointment daily. From this moment on, a kind of stability in the transition journey emerges; the launch phase is over, medical and psychological follow-ups are in place. The transferential relationship experiences calmer days than at the beginning. Several months have passed. The technical hazards of his transition take up less space; the treatment is a routine; he can give free rein to his thoughts during the sessions, and the content of the psychic material brought changes considerably, thanks to this stability of follow-up.

“Testogel^® is like a drug now, I can’t do without it… Well, a drug, not really; it’s more like a beauty product, it’s my personal essence… Because basically, testosterone is indeed a substance; it’s chemistry that penetrates me through the skin, passes into my blood, and irrigates my whole being. I feel it in me, it circulates in my veins. Since the first dose, it’s the same thing every time, I feel when it takes effect, like a ‘hit’ or something.”

The daily intake of testosterone via the percutaneous route now rhythms Marc’s life. It is certainly not the start of this hormonal treatment alone that dates the entry into transition, as this must be assessed with other factors, but it is a daily and significant marker of it. Marc applies the hormonal ointment to his thighs as soon as he wakes up. Thus, his hormone intake remains qualified as a “dose” and not an application, although not swallowed as a tablet, unlike a per os treatment. It is not associated with washing, nor with breakfast, nor with dressing. It is a moment in its own right, a boundary moment between waking from sleep and getting up; this seems significant to us.

from substAnCe to the object

 

Since the first hormone dose, something has changed inside. The general feeling is gradually permeated by a new atmosphere, then by new feelings, new ideas, new behaviors, new desires. Marc, moreover, situates the nature of these novelties among what he considers the late advent of a self finally released, restored to its sensations, as if these had always been perceived within, awaited, dreamed of, hoped for, fantasized, and the hormone gave them form and body. Testosterone indeed acting on mood, thought, sensations, and the entire body, it opened the way to a new being. Marc does not speak of it as a rebirth, nor as the extraction of a masculine personality that would have been imprisoned in a feminine body before being released. He also readily criticizes this common representation of gender or sex transition journeys, sometimes claimed by the individuals themselves, where nature would have deceived a female personality by trapping it in a male body,

or vice versa. This is because Marc considers himself to be in a “gender” transition, not a “sex” transition, although he uses the phrase “sexual journey.” He does not plan to resort to surgery to benefit from a sexual reassignment, a phalloplasty in his case. While the removal of his breasts is considered in the medium term, this operation does not, from his point of view, fall under a bodily modification affecting sex, because it is non-genital according to him. His journey is, for him, the exact opposite of the surgical approach; it has nothing to do with aesthetic transformations because they are visible from the outside. Testosterone embraces at its heart the person he tends to be, not to look like a man, even if that is important too, but to be a man from inside the body, from his mind, his thoughts, where for him the truth of Man resides. However, we cannot neglect the reality of the transformations, visible on the outside, that testosterone induces. Several elements invite us to discussion here. The evocation of addictive behavior in the daily application of hormones highlights the repetition, of which we must be able to say what it covers. Testosterone is not without effects: body hair, skin texture, hair quality, muscle mass gain, vocal modulations—all bodily effects that echo the changing feelings, ideas, affects, and behaviors, with a psychoactive dimension, mentioned above. Moreover, its penetration into the organism through the skin accentuates this idea of the substantification of “being a Man” into a balm. Testogel^® is then a kind of anointing endowed with powers of transformation that we can assimilate, when it is taken, to a dose ⁹, or a magic charm. Is it a hit nonetheless? No flash, as an intravenous injection of heroin causes, although Marc’s identification of a peak effect, a few minutes after applying the ointment, should be noted. The physical constraint that the definition of addiction ¹⁰ encourages us to identify, to appreciate the interest of this conceptual recourse ¹¹ in our elaboration, is not blatant. On the other hand, the “hook”—as we say of a drug one gets hooked on—perceived here testifies to another dimension of the bond, including dependency, when it contributes to being-in-the-world. The involvement of the bodily envelope occupies the front of the stage in Marc’s discourse; it is an important datum.

This propping up by the skin, where sensations take root before spreading, can be read with Anzieu’s conception developed in The Skin-ego ¹². In this light, are the sensations described by Marc then those that the infant perceives and upon which they rely during the first moments of their aerial life? Do they appear as the target of the treatment, a possible treatment of this historical propping up (at least its development), or even its persistence in the present? The ointment passes through this supporting surface and gateway that is the skin, to reach internal sensations and modify them. Marc’s history and mnemonic heritage are directly summoned by this maneuver which consecrates them as an expression of the infantile. Is it therapeutic, since it is a matter of treatment? What do these sensational novelties bring or awaken from Marc’s experience? It is impossible to answer this question here ¹³, but we must note how the very modalities of the technical mode of his transition borrow, fortuitously or fortunately, the paths of his subjective construction, and demand to be perceived as such. Transition prolongs, resumes, repairs, amends, distinguishes, or renews what, for the subject in the making, is only transition, from their prehistory, in the sexual landscape. The clinic obliges us to think about these data in this movement and encourages us to read Marc’s approach as an echo of his subjective constructions and identifications, from substance to subject, via the object.

 

gender, an object of AddiCtion?

 

Less addiction than substantification, or the involvement of substance, we must however clarify Marc’s use of this reference to drugs and physical and psychic dependency. On this point, the written testimony of Beatriz Preciado ¹⁴ enlightens us. The philosopher explains, in Testo Junkie ¹⁵, the stages of her daily testosterone intake for 248 days. This is an opportunity for the author to develop her reflection on questions of sex and gender, and sexual politics. The title evokes addiction to “testo,” and the content of the narrative specifies the scope of this approach. Her performances are part of a completely different perspective from a project

This propping up by the skin, where sensations take root before spreading, can be read with Anzieu’s conception developed in The Skin-ego ¹². In this light, are the sensations described by Marc then those that the infant perceives and upon which they rely during the first moments of their aerial life? Do they appear as the target of the treatment, a possible treatment of this historical propping up (at least its development), or even its persistence in the present? The ointment passes through this supporting surface and gateway that is the skin, to reach internal sensations and modify them. Marc’s history and mnemonic heritage are directly summoned by this maneuver which consecrates them as an expression of the infantile. Is it therapeutic, since it is a matter of treatment? What do these sensational novelties bring or awaken from Marc’s experience? It is impossible to answer this question here ¹³, but we must note how the very modalities of the technical mode of his transition borrow, fortuitously or fortunately, the paths of his subjective construction, and demand to be perceived as such. Transition prolongs, resumes, repairs, amends, distinguishes, or renews what, for the subject in the making, is only transition, from their prehistory, in the sexual landscape. The clinic obliges us to think about these data in this movement and encourages us to read Marc’s approach as an echo of his subjective constructions and identifications, from substance to subject, via the object.

 

gender, an object of AddiCtion?

 

of transition aiming to move or redefine oneself in the ordinary sexual passage; Beatriz Preciado’s objectives do not intersect with Marc’s. Let us say that Preciado’s project is not a transition project; she is more in an intellectual and sensational exploration within the framework of her research, which here finds its form of performance. She announces:

“I do not take testosterone to transform myself into a man, but to betray what society wanted to make of me, to write, to fuck, to feel a form of post-pornographic pleasure, to add a molecular prosthesis to my identity ¹⁶.”

This refers us much more to the “no future” discourse of a drug culture of the eighties, or to a rhetorical exercise, rather than to the statement of the necessities that govern the engagement in a transition journey as we encounter it in the clinic. Nevertheless, the exploration of her “voluntary intoxication,” as this text offers us to appreciate all its refinements, highlights common and clinically identifiable identity representations, which we link to the social invisibility of trans man – FtM identities. Let us recall in this regard that FtM and MtF transition journeys, as we identify them by these letters which suggest a symmetry that does not exist, ultimately have little or nothing in common; we will have the opportunity to return to this in detail ¹⁷.

Then dependency on the substance can be understood at the threshold of objectal libidinal investment, when it detaches a little from narcissism in favor of the outside, as Freud proposed in 1914 ¹⁸. From the thing to the object, in a way, such is the path that transition through hormones perhaps offers to walk a little. This is because the product is already an object, which can become an object of addiction or a fetish object; we will talk about it. If the substance can then be thought of as a prerequisite to the object, which does not imply being preceded by it, some of them can present themselves immediately to the subject, the phallic object for example.

Thinking of the application of testosterone as drug consumption highlights, beyond the product that it is not necessarily, what the substance nevertheless comes to produce in the place of the subject in the making. Felt,

perceived, experienced—this is indeed a register that invites us to think of the notion of primal repression, when on the traces of an experience whose modality of loss implies that its reunion does not return in the same mode as the ordinary repressed, we are led to pin down its appearances with the patient who is groping. This pre-objectal or peri-objectal substance merges with the materiality of the body itself, its biology, its organic living character. Can transition with hormone intake and its effects signal its return? We maintain here that the use of gender testifies more certainly to a process of election of what it represents and the function it performs for the subject, but much less to the appeasement of the object of addiction with which it is nevertheless labeled in its presentation. For the support or propping up it makes possible does not short-circuit the path of affects, quite the contrary ¹⁹.

hAndlings of gender in the Clinic

 

Since gender emerges, its use does not proceed, in our view, from a use from which it would be possible to derive profits or actions, but much more from a handling. Our conception, on this point, differs radically from the criticisms voiced against those who would delude themselves with a “use” of gender as Charles Melman argues ²⁰ with others. Those who seize it—the patients—do not resort to it like an objectal investment propping up identity or prosthetizing the body. They go through gender out of necessity. It allows for the reconsideration of subjective impasses or difficulties because it is articulated, as a symbolic process and imaginary object, to sex which we define as an imaginary instance and symbolic object—as the gender clinic in psychoanalysis ²¹ teaches us and by virtue of which their relationship is not one of complementarity but of knotting. In this configuration of the sex-gender relationship, gender is a vector of sexuation capable

1. J. McDougall conceives that the recourse to the addiction object aims at the short-circuiting of affects, in an attempt at appeasement and management.
2. C. Melman, “Editorial,” Le bulletin lacanien, No. 4, Sex and Gender, Paris, Association lacanienne internationale, 2008, p. 9-11.
3. On the occasion of our doctoral thesis “Gender clinic in psychoanalysis,” we defined gender, sex, and sexuation in their correspondences with the imaginary, symbolic, and real registers based on their quality as object, process, and instance. The result offers us the following coordinates:

	Imaginary	Symbolic	Real
Gender	object	process	impossible instance
Sex	instance	object	impossible process
Sexuation	process	instance	impossible object

to work on the building of representations of the sexual in the subject’s social reality (including sexual identity, for example). The psychoanalytic cure would here aim at the conditions of this construction. Several types of handling emerge; our example illustrates in particular a handling of gender from the imaginary object, but other access routes exist; we will return to them. It is therefore appropriate to identify this handling of gender in the transferential space, by distinguishing the elements relating to the counter-transference or the analyst’s part, from the psychic work carried out by Marc.

From gender as substance, Marc gradually manufactured something in relation to his body, a new and renewed body. This production manifested itself in alternating moments of passing through the formless ²² of a great subjective destabilization, always experienced on the edge of rupture. Symptoms of depersonalization and hallucination occurred, always fleeting, always criticized, which we have more or less repatriated each time into the psychic creation underway in the transferential space. Anxiety attacks temporarily required the support of drug treatment, in coordination with a partner psychiatrist. Sensory disturbances and quasi-delusional productions were not treated with antipsychotic or other drugs, in agreement with the psychiatrist. Their brief temporalities encouraged us, at each stage, to integrate them successively into the analytical work, their status then being more a matter of a de-subjectivation at work that deserved to be welcomed in the transference to find its resolution.

Marc had already demonstrated to us his ability to handle gender as a symbolic process mobilized in a progressive reinvestment of the body and language, notably through the production of new words intended to designate each part of his body, one after the other, like a reissue of the first discovery. This fruitful moment of work gave way, after a few months, to the emergence of gender as an imaginary object, whose composition first found its form and matter in these moments of passing through the formless. This is because the opening induced by the recourse to gender engaged the creation of a new sex—and not just a new sex. At this level, the analyst is called upon in a specific way when the imaginary of gender invites itself into them to give body—and therefore image—to the gender in the making of the analyzing subject and to this new sex co-occurring with the gender at work. For if gender is put to work, it is to reinvent sex, as we will further explain.

But how did it work? What psychic processes, particularly unconscious ones, can we describe? When gender resonates with its quality as an imaginary object and symbolic process, it comes to discuss sex in its quality as an imaginary instance and symbolic object, and it questions it, even highlighting the precariousness of the knowledge that accompanies its existence, for the subject and for the analyst. Sex thus challenged in its construction reveals the known, still unknown, or to-be-recognized identificatory movements of what in the analyst’s analysis was able to shed light on the constitution and sexual authorization of the sexed being, the semblance of a woman or a man by which the analyst identifies, for example. This engages the analytical work on the path of a sexuation now thought of as an imaginary process and symbolic instance. This is a first level of the analyst’s work on sex through gender, when the analyst proposes to support the analysand’s desire for analysis based on the knowledge they have themselves developed for their own account, on their own account, and which they continue to clarify further, each time a cure invites them to move bodily within the matrix of their knowledge.

But the psychic elaborations, encouraged by each advance in the analytical work, flourish in the dream activity or the symptomatic productions of the patient, but also in those of the analyst. A specular and non-specular representation of gender gradually emerges on the analyst’s side. One part allows itself to be represented and said; the analyst thinks or speaks it; another part resides outside the field of language; the analyst hosts and tends to it.

This cohabitation of the analyst with this gender in construction-elaboration is permeated by what the counter-transference “classically” involves. But it above all defines a workspace where imagining the outline of gender at work and in simultaneous construction then allows it to be written. And that it be written gives an edge to the off-field of speech where gender can come either to overwhelm and prevent the elaboration of the analysand’s new sex, or to support and dynamize this creation that the analyst can take on as beyond the matrix, a matrix finally pacified from the void on which it rests. This is a second level of the handling of gender by the analyst.

In another access route to the handling of gender, which Marc’s case allows us to generalize, we note that gender introduced into analytical practice notably allows for the reconsideration of identity. Identity does not account for the identifications that found it in all their truths; this may explain the mistrust or lack of interest in identity on the part of psychoanalysts. Does not a psychoanalytic cure, moreover, aim to deconstruct identity in a certain way to renew the libidinal investments that it sometimes crystallizes too severely to the

point of generating impediments or symptoms for the subject? This perspective of the psychoanalytic experience is obvious, but we question it today. Our liberal society continues to put into orbit the conditions of an identity political regime where the prosthetic virtues of the identity character prevail. We can consider our immobility or our assurance in the face of this social reality, but we can also shift our point of view; the gender clinic allows us to do so.

Identity reveals itself with gender to constitute a pole of symbolic narcissistic attractiveness that it would be detrimental not to seize. It is, moreover, a way of defining it by stating that gender is the sexual pinned down by narcissism. And it is in its quality as a symbolic object that sex is then accessible and questioned by this handling of gender that we qualify as symbolic. Indeed, by inviting identity without fearing the effects of dilution or identificatory synthesis that it represents, we take up the trace described by Lévi-Strauss in 1975: “[…] identity is a kind of virtual focus to which it is indispensable for us to refer to explain a certain number of things, but without it ever having a real existence. […] a limit to which in reality no experience corresponds ²³.” In doing so, virtuality offers us to suspend sex as a symbolic object. We can in this way hold sex, lift it temporarily, artificially, and peel it away from the identity that it never takes very long to qualify as sexual. We know it, clinical experience convinces us of it, identity ends up sooner or later revealing itself in its sexual dimension; it is always sexual identity that we arrive at when we deal with identity in the cure, even applied to other narcissistic elements, whether we approach it through biography, genetics, or family heredity. Then gender thus handled unfolds identity and what should be designated as the subject’s sexual identity spectrum, where object choices and libidinal investments are found to be approachable in a new dimension, that which finally sex relieved of its symbolic functions allows to appear. We find there the path to sexuation, as an imaginary process, an unconscious process once again accessible. We can summarize this maneuver as follows: handling gender to lift sex and reach sexuation. Gender thus becomes a vector of a rewriting of symbolic scope aiming to modify sexuation as a symbolic instance, and thereby sex as a symbolic object in return, and thus the subject’s sexual identity. Gender undoes sex and creates sex, where the created sex is distinguished from the undone sex by being for the former that of the individual belonging to the species, for the latter that of the subject that the cure aims to accomplish.

To ConClude

 

The analytical work at work reaches, in the intensity of the goals pursued, levels of production and psychic rearrangement that undoubtedly touch upon the structure, which often gives them the appearance of irremediable crossings. Therapeutic support, psychoanalytic support must here take up the challenge of a fine reading of the proppings that are built and elaborated from the transferential relationship. Then perhaps gender is the name of this moment of transferential elaboration that unfolds concerning the sex of the other in the cure? Perhaps it is the name of what we identify as a line of work where it would be appropriate to explore the function of the analyst as this

“other of the sexual”? Perhaps it is the name of a place of sex in the psyche?

We have seen how the recourse to the patients’ gender quickly becomes the possibility of a handling of gender by the analyst, if they respond to this invitation made to them. Its introduction into the analysis seems to highlight that the cure occasions a potential creation of the analysand’s new sex. Our experience with Marc supports that its handling then goes beyond the simple renewal of sex, or sex embellished with gender when the latter is considered as the counterpart of sex in the social sphere. Gender, consequently, imposes itself much more as a limit between the sexual and the social, which psychoanalysis is entitled, in duty, from our point of view, to enlighten.

bibliogrAPhy

 

AlessAndrin, A. 2012. From “transsexualism” to Trans becomings, sociology thesis, University of Bordeaux Segalen, defended on June 10.

Anzieu, D. 1995. The Skin-ego, Paris, Dunod, 291 p.

BeAtie, T. 2008. Labour of Love: The Story of One Man’s Extraordinary Pregnancy, Seal Press.

beh. Weekly Epidemiological Bulletin, No. 42, November 22, 2011, invs (National Institute for Public Health Surveillance), Paris, invs.

butler, J. 1993. Bodies That Matter: On the Discursive Limits of

“sex”, Paris, Amsterdam, 2009.

CAlifiA, P. 2008. Sex and Utopia, Paris, La Musardine.

Freud, S. (1914-1914) “On Narcissism: An Introduction,” in Complete Works,

vol. 12, Paris, Puf, 2005, p. 215-245.

HoffmAnn, E.T.A. 1817. “The Sandman,” in Fantastic Tales 2, Paris, Garnier-Flammarion, 1980.

JentsCh, E. 1906. “On the Psychology of the Uncanny,” The Uncanny. Psychotherapeutic Studies, Imaginary and Unconscious, No. 17, Brussels, De Boeck Université, 1998, p. 37-48.

LAufer, L.; LinhAres, A. 2010. “Foreword,” Champ Psy, What gender does to psychoanalysis, No. 58, Paris, L’Esprit du temps, p. 7-8.

Lévi-StrAuss, C. 2000. Identity, Paris, Puf, p. 332.

McDougAll, J. 2001. “The Psychic Economy of Addiction,” in Anorexia, Addictions and Narcissistic Fragilities, Paris, Puf, p. 11-36.

MelmAn, C. 2008. “Editorial,” Le bulletin lacanien, No. 4, Sex and Gender, Paris, Association lacanienne internationale, p. 9-11.

Morel, G. 2008. The Law of the Mother, Essay on the Sexual Sinthome, Paris, Anthropos. PreCiAdo, B. 2008. Testo Junkie, Paris, Grasset.

Stoller, R. 1978. Research on Sexual Identity, Paris, Gallimard.

 

Abstract

What do we make of gender in clinical practice? How does it emerge, and what handling, what practice can we adopt? Based on clinical elements, this article aims to describe the uses of gender by subjects and to shed light on the opportunities they present for the analyst, should they choose to consider them as therapeutic avenues. From substance to object, gender questions our approach to addiction, incorporation, and the construction of the body, during a profound reorganization. This opens up dimensions and registers, both imaginary and symbolic, where the analyst can welcome psychic constructions that contribute to the arrangement of the subject’s sexuation, via gender as a vector.

Keywords

Gender, object, substance, sexual identity, transsexuality, transgender, constructions

EMERGENCE AND HANDLING OF GENDER. FROM SUBSTANCE TO OBJECT

Summary

What do we make of gender in clinical practice? How does it emerge, and what handling, what practice can we adopt? Based on clinical elements, this article aims to describe the uses of gender by subjects and to shed light on the opportunities they present for the analyst, should they choose to consider them as therapeutic avenues. From substance to object, gender questions our approach to addiction, incorporation, and the construction of the body, during a profound psychic reorganization. This opens up dimensions and registers, both imaginary and symbolic, where the analyst can welcome psychic constructions that contribute to the arrangement of the subject’s sexuation, gender as the vector.

Keywords

Gender, object, sexual identity, transsexuality, transgender, constructions