Anon 0451 cohort SPH3 2/08

The psychology of a teenage

hermaphrodite; is it Body
Dysmorphia to deny sexual
attributes?
The incident I am reflecting upon has made me stop and think on several
occasions as it is unlikely I will come across a similar circumstance within my
career. Despite this, I think it is worthwhile to reflect fully on the slim chance I
encounter another hermaphrodite with a gender identity crisis. I have decided to
utilise the model of reflection as suggested by Gibbs (1988). This will allow me to
present my recollection and interpretation with regards to underlying psychology
and whether or not established therapies and surgical interventions resolve the
issues within.

What happened?

We were called to a 17 year old male who was suffering a panic attack,
hyperventilating and struggling to talk. It transpired that this young man had
been born with both sets of sexual organs and currently was undergoing various
surgeries to establish his gender as male. Further to his hysterectomy, he was
awaiting mastectomies; but resorted to wearing a tight fitting corset to bind his
bust. This constantly aggravated his breathing and subsequently he has become
prone to hyperventilation at times of stress. He attempted to be dismissive of
his dyspnoea worrying more about his girlfriend and how they were going to get
home.

What was I thinking and feeling?

Upon discovering this young man had a significant (b cup) bust, I was able to
discuss clinically the underlying cause. I asked if it was gynaecomastia or a
trans-gender issue and from there the patient was very open about it. I was very
conscious not to appear surprised or disorientated by this and am confident that
the patient benefitted from this. This allowed for positive transference and
minimised counter-transference. Transference being a hypothesis of Freud

1
Anon 0451 cohort SPH3 2/08

(1912) and has been repeatedly utilised in psycho-analytical models such as the
core conflictual relationship theme (CCRT) (Luborsky et al. 1991, Luborsky 1993)

What was good and bad about the experience?

I believe this rare physicality in a patient prompted me to consider the possible

psychological definitions with regard to the tight binding to reduce the female
attributes. At first I considered body dysmorphia as the issue, but I quickly
established that such an abnormal psychology arises from a distorted self
perception; such as in those with anorexia nervosa, bulimia or muscle
dysmorphia in men who resort to androgynous anabolic steroidal (AAS) abuse.
Veale (2004) describes and analyses Body Dysmorphic Disorder (BDD) very
thoroughly and was the anchor for my research into BDD. I don’t believe that a
teen male with breasts could be described as having a distorted self perception.
The fact of the matter is that this young man perceives a trait which has yet to
be resolved surgically; it is all too real.

What sense can I make from the situation?

Eliminating BDD early on left me looking more at the transgender issues

themselves and what psychological support is effective for those struggling to
come to terms with their gender variance.

In 1973, homosexuality was declassified as a mental disorder by the American

Psychiatric Association yet variance from traditional gender identity remains a
psychiatric classification; transvestism fetishism and gender identity disorder
(APA 1994). There is of course a need to realise the psychology of patients who
are very well adjusted people despite this side of their nature.

The majority of psychological thinking with regard to hermaphrodites endeavours

to attach them as a sub-set of Lesbian, gay and bisexual psychology (Gainor,
Greene, Croom 2000). In Transgender Emergence (Lev 2004) the author points
out that when gender variance of any sort is addressed by society, psychology
and surgery, it creates a framework of personal abnormality to try and achieve
the societal norm of male or female.

2
Anon 0451 cohort SPH3 2/08

My patient appeared very well adjusted. I am not qualified to suggest or

diagnose any abnormal psychology; but I believe he had established what
gender he should be by choice or chromosome. He endeavoured to present an
appearance of normality by reducing his female traits. I would say that this is
normal behaviour, though perhaps it should be done less aggressively, maybe
baggy shirts rather than tightly bound corsetry. It is recorded that transgender
or gender variance can provoke violence and abuse from some parties (Lev
2004) so the patient’s approach to his appearance is sensibly based.

I am somewhat flattered by the patient being able to share such an intrinsically

personal gender variance with me. It definitely allowed me to be forward thinking
with regards to immediate treatment and therapy for the hyperventilation and
distress. It also gave me a rare opportunity to ask questions regarding a very
rare case of sexual dimorphism/hermaphroditism.

Without a doubt the strongest psychological aspect in such cases is

biopsychology. The influence of the endocrine system, the anatomical
differences and the genetic s and chromosomes of a hermaphrodite are a
boiling pot of reductionist traits. Obviously the surgical and hormonal treatments
will improve the psychological outlook of such a patient, but I am very certain as
a layman in this field that cognitive therapies and human interaction and
discourse are far more beneficial on the long run. Just surgically changing
someone cannot address all the reasons for wanting the surgery.

If it arose again, what would I do?

I think any patient, who exhibits a physical trait which most would see as an
abnormality or disability must not be seen in this way by any clinician. The
prevalence of abnormal psychologies in such cases is made more prevalent by
the attitudes and transference of those who the person interacts with.

Personally, I have considered plastic surgery. The minor variance to a societal

norm by having loose skin at my waist causes me a fair amount of distress. I
have researched over 5 surgical procedures and 2 non-invasive procedures as I
could be said to have mild body dysmorphic disorder. The psychological impact
of having both sets of reproductive organs would be of a magnitude I am not
sure I can comprehend; and I wonder about the prevalence of post surgical
psychoses such as depression in these cases.

3
Anon 0451 cohort SPH3 2/08

If I come across a patient such as the young man who showed great courage and
stoicism to his condition, I hope I can receive some transference from him or her.
I believe as a paramedic, our practice can be best served by asking patients to
explain their perceptions, rather than us imposing ours.

Word count: 1070

References
Freud S (1912)
The dynamics of transference
Essential papers on transference analysis,
1912 - Jason Aronson

Gainor K (2000)
Education, research, and practice in lesbian, gay, bisexual, and transgendered psychology.
A Resource manual
Edited by Beverly Greene, Gladys L. Croom,
Society for the Psychological Study of Lesbian and Gay Issues.
Sage publications Inc.
California

L Luborsky, P Crits-Christoph, SH Friedman, D Mark and Pamela Schaffler (1991)

Freud's transference template compared with the core conflictual relationship theme
(CCRT): Illustrations by the two specimen cases.
University of Chicago Press

Luborsky, L., Luborsky, E. (1993)

The Era of Measures of Transference: The CCRT and other measures.
Journal of the American Psychoanalytical Association. 41S:329-351.

Veale D (2004)
Body Dysmorphic Disorder
Post Graduate Medical Journal 2004; 80:67–71.BMJ