Dissociative Identity Disorder
Journal of Psychology and Christianity
2012, Vol. 31, No. 3, 278-284
Copyright 2012 Christian Association for Psychological Studies
ISSN 0733-4273
278
Early in the heyday of DID, ego-state theorists John and Helen Watkins were observing opposite gender ego states and suggesting that sexual iden- tity needed to be studied from an ego-state per- spective (Watkins & Watkins, 1982). They reported that opposite gendered ego states seemed to be organized around the stereotypes of maleness or femaleness. More recently, Howell (2002) has speculated that much of gendered behavior, and especially its pathological extremes, derives from trauma and that specifically gen- dered self-states are created by trauma. While opposite-gender identity states may be highly stereotypical, the outward presentation of the DID patient is often more unisex, which allows for opposite-gender identities to emerge without cre- ating confrontations or awkward situations in their interpersonal world (MacGregor, 1996).
Although the early literature in this area seemed to affirm the scientific legitimacy of studying the potential relationship between opposite-gender identities and sexual orientation, the subsequent evolution in the social and professional cultures as regards homosexuality appears to have brought such inquiry to a halt. I believe that the subject still indeed has merit, but certainly it is complex, controversial, and ultimately beyond the scope of this paper. Instead, using composite case material, I intend to focus more pragmatical- ly on the manifestation of same-sex behavior and attractions in DID patients that arise from the activity of opposite-gender identities. By review- ing the psychodynamics of this phenomena, I think important insights can be gained for the therapeutic care of DID patients as well as a sub- set of adult victims of childhood trauma who report same-sex attractions and behavior.
Case Material
Gina was a 27-year-old single Christian woman who had been referred for psychotherapy by the church where she had been helping in college ministry. Her referral was precipitated by the dis- covery that she had engaged in homosexual behavior with another woman whom she had met during a community-wide church event. Though historically depressed and emotionally over con- trolled, this impulsive act so startled Gina that she readily consented to treatment. Over the course of several months in therapy, it became evident
Opposite-Gender Identity States in Dissocia- tive Identity Disor der: Psychodynamic Insights into a Subset of Same-Sex Behavior and Attractions Christopher H. Rosik Link Care Center/Fresno Pacific University
Dissociative Identity Disorder (DID) is a psycho- logical condition wherein the individual experi- ences (1) the presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self), of which (2) at least two of these identities or per- sonality states recurrently take control of the per- son’s behavior, resulting in (3) an inability to recall important personal information that is too exten- sive to be explained by ordinary forgetfulness and is (4) not explained by substance abuse or a gen- eral medical condition (American Psychiatric Asso- ciation, 1994; International Society for the Study of Trauma and Dissociation, ISSTD, 2011). Generally, DID is considered a trauma-driven disorder, pre- sumably originating out of recurrent abuse com- mencing in early childhood. While subjectively compelling for the patient, these alternate identi- ties are not separate persons but rather enactments of trauma related intrapsychic conflict, memories, and affects (ISSTD, 2011).
Child, persecutor, and protector identity states are often exhibited by DID sufferers. A less well noted but relatively common alternate identity for these patients is one that takes the form of the opposite-gender (e.g., a male identity state in a biologically female patient). Early accounts in the literature suggested that approximately 50- 66% of DID patients have at least one opposite- gender identity (MacGregor, 1996; Putnam, 1989; Ross, 1989). Putnam indicated that child, adoles- cent, or adult male personality states are found in about 50% of female patients and approximately two-thirds of male patients present with a female alternate identity. Ross found that 62.6% of a sample of 236 DID cases evidenced a dissociated identity of the opposite gender.
CASE STUDIES
Correspondence concerning this article should be addressed to Dr. Christopher H. Rosik, Link Care Cen- ter, 1734 W. Shaw Ave., Fresno, CA 93711. E-mail: christopherrosik@linkcare.org
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that Gina was reporting symptoms that could be explained by the activity of dissociated identity states. These included experiencing internal ego- dystonic voices, not recognizing her face in the mirror, not recalling some things others told her she did, and sometimes perceiving her environ- ment as if she was looking through the small end of a pair of binoculars. Following a period of psychoeducation regarding dissociative experi- ence and the mobilization of her limited support system, I conducted interventions aimed at con- tacting potential alternate identities. This con- firmed a DID diagnosis.
One of the dissociated personality states, who identified himself as "Alex," took responsibility for the homosexual behavior. As Gina's dissociated trauma experience began to be pieced together through the accounts shared by her alternate identities, it became evident that she was report- ing a series of sexual molestations beginning in childhood, first by her stepfather and sometime later by an uncle. While caution should always be taken not to assume the veridicality of report- ed abuse memories in DID patients, memories of ordinary childhood abuse among DID patients have been highly corroborated (75-90%). Memo- ries of ritual abuse are rarely corroborated (0- 20%) and are not likely to be literal, historical events (Dalenberg, 2006; Lewis, Yeager, Swica, Pincus, & Laws, 1997; Kluft, 1995; Rosik, 2003). Gina reported that neither of her two younger brothers had experienced similar sexual abuse by her stepfather, and Alex indicated he had come to make sure that Gina would receive the same reprieve from further sexual trauma.
As Gina grew up, Alex reported becoming more sexually interested in girls as “that’s what guys do.” Gina acknowledged in therapy that she had struggled, sometimes quite intensely, with sexual attractions to some of the women in her history and had resisted acting on these attrac- tions in large degree because of her religious val- ues. However, she also recalled that a few of her past female friends had abruptly terminated their friendships, citing behavior from Gina which they felt to be overtly sexual in nature. Gina was baf- fled by these accusations and could not imagine herself having engaged in such conduct.
As trust was built with the alternate identities, Alex confessed that he had pursued these rela- tionships but found “that prude” Gina often got in his way. Even more frustrating to Alex was that on those few occasions when he was able to assume control of the body and initiate sexual
overtures, Gina’s female friends were “so reli- giously hung up about sex” that they refused to respond in kind. My treatment did not involve directly challenging Alex’s views about same-sex behavior; indeed, Alex did not even view his activity as being homosexual in nature and such an approach would have likely destroyed our alliance. Gina’s sexual behavior in general was not a specific focus of her therapy. Instead, my treatment involved interventions common to DID. As regards Alex, his fundamental, trauma driven cognitive distortions needed to be chal- lenged, including his belief in having a separate body from Gina’s and his need to be oriented to the present where further trauma was no longer an immanent threat. Alex began to question his own dissociative understanding of himself and the outside world. The facilitation of communi- cation among Gina’s alternate identities further eroded the dissociative barriers and provided a greater context for Alex to empathically under- stand the nature of the trauma they had experi- enced, eventually leading to significant grief work that included Alex’s deeply hidden feelings of failure for being unable to prevent some of Gina’s abuse. A growing sense of Christian-ori- ented spirituality within Gina’s system of alternate identities also gave momentum to the therapeutic process, and this was instrumental to relieving Alex’s feelings of failure and guilt.
In the end, as Gina listened to her dissociated identities and gained a more coherent sense of self, Alex willingly integrated with Gina’s increasingly united consciousness. Interestingly, Gina reported that her experience of same-sex attractions and conflicts were greatly reduced, though she sometimes noticed them temporarily during particularly stressful circumstances in her life. This could be interpreted as a brief reacti- vation of her formerly dissociated Alex ego state, but not to the point of a renewed dissociative split. As is typical for DID treatment, integration of the dissociated personality states marked the beginning of Gina learning to live without disso- ciative coping mechanisms and having to devel- op more adaptive coping skills. The treatment needs related to Alex would not be complete without assisting Gina post-integration to devel- op greater skill and comfort in her social rela- tions (particularly with men), a task which took significant time to accomplish despite her great desire to achieve a level of heterosexual func- tioning that was satisfying to her.
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Psychodynamic Considerations with Opposite-Gender Identities
Understanding the psychodynamic functions of opposite-gender identities such as Alex can aid therapists in the treatment of complex trauma in general and some forms of unwanted same-sex behavior in particular. Ross (2002) suggested that opposite-gender identity states can be based on trauma driven reaction formation to a primary het- erosexual identity. They may often be defensive adaptations to a same-sex or opposite-sex abuser and can be active in homosexual or heterosexual behavior, leading to great confusion about sexuali- ty (Putnam, 1989). The psychodynamics of these alternate identities appears to be somewhat differ- ent for women and men DID patients, which justi- fies the separate examinations below.
Male identities in female patients. The literature on opposite-gender identities in
female DID patients has reported a number of psychodynamically compelling reasons for their formation. These reasons are not necessarily mutually exclusive and more than one may be relevant to a single identity state or be portioned among different states within the same patient.
Protecting the physical and psychological integrity of the self. Gina’s case highlights the function of male identities (Alex) serving as a kind of bodyguard to protect the patient from the continuation of trauma. In such cases, the dynamic origin of these differently gendered alter- nate identities have much more to do with pre- serving a sense of strength and safety (real or imagined) than they do with anything sexual. Such identities can present quite masculine in their appearance, speech, and behavior (Putnam, 1989; Ross, 1989). The dominance of a male alternate identity may also result in the female DID patient assuming an apparent lesbian role (Watkins & Watkins, 1982). Alex’s presence was clearly established in a psychic attempt to protect Gina from the reality of her powerlessness in the face of sexual abuse. By creating a part that iden- tified as male, she was able to dis-identify with the victimized and vulnerable reality of her female self, and in this way achieve some degree of internal psychological mastery over her abuse.
Persecuting/Identifying with the perpetrator. Another method of dynamically trying to undo the childhood trauma is by creating a male alternate identity that persecutes the host personality state and/or victimizes other women (Howell, 2002; Ross, 2002). Such male identities enable DID
patients to shift from the role of victim to that of a perpetrator and in so doing gain a psychological sense of control and mastery over their potentially self-destroying traumatic circumstances. Homosex- ually oriented female alternate identities in female patients may also sexually victimize women, but in this case the assumption of the perpetrator role may also serve to enable the patient to avoid the intense fear of sexual contact with men.
Avoiding the opposite sex. Ross (2002) observed that homosexual male alternate identities in female DID patients permit sexual intimacy and good heterosexual functioning with men while dis- sociating the fear of intimacy and sexual conflict often linked to the identity of the female victim of male abusers. Such an identity may embody the homosexual adaptation of the patient and serve as a denial of her heterosexual drive (Ross, 1989). This psychological adaptation constitutes a reaction formation to the trauma driven fear and phobia of men and may constitute a form of secondary les- bianism (MacGregor, 1996; Ross, 1989). Alex appeared to have developed this function subse- quent to Gina’s entrance into puberty.
Tolerating unacceptable sexual contact. Male alternate identities in female DID patients can also provide a mechanism for achieving healthier sexual intimacy with women while avoiding the fear and conflict linked to the identi- ty of the female abuse victim (Ross, 2002). They may also serve the defensive function of shielding the patient from conflict regarding her lesbian sexual behavior, which is common among reli- giously conservative patients. This dissociative strategy solves the problem of how to have sex with a same-sex partner while maintaining a het- erosexual self-identity (Ross, 1989). A homosex- ual-oriented female alternate identity can also accomplish this task.
Procuring intimacy and affection. Since the female DID patient sexually abused by male per- petrators typically have great difficulty in their sex- ual relationships with men, male alternate identities who are sexually attracted to women may also serve as a primary means of obtaining physical inti- macy, affection, and warmth (Ross, 1989). Here sex is a secondary issue in their sexual behavior. In female patients where value conflicts regarding homosexual behavior are not present, homosexual- ly-oriented female identities may be the more com- mon means of gaining comfort.
Per for ming “masculine” tasks. Putnam (1989) noted that male alternate identities in female DID patients sometimes serve as
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mechanics or otherwise operate machinery. This function is not specified in the rest of the literature. However, it is likely that some male identities are created to assist in tasks that are culturally masculine, such as mechanical opera- tions or sports activities.
Female identities in male patients There is much less literature devoted to the pres-
ence of female identities in male patients. Only Putnam (1989) addressed this topic in some detail, suggesting that such female identities usually come in the form of an older "good mother" figure. This identity functions to provide comfort and attempts to soften what is often angry and destructive behavior of male DID sufferers. While Putnam asserted that male DID patients are somewhat more likely than female patients to have opposite- gender identities, this statement has not been repeated or confirmed in the subsequent literature.
Transgenderism and transsexualism Worth mentioning in the context of opposite-
gender identities are their potential involvement in certain cases of transgender and (should sex- change surgery be pursued) transsexual identi- ties. Putnam (1989) noted that many male DID patients present with host states that are out- wardly effeminate and often homosexual in ori- entation. He further observed that in cases where the opposite-gender identity perceives the body's actual anatomical sex, there may be attempts to change it, including sex-change surgeries. Ross (1989) also suggested that the phenomenon of transexualism may be dissocia- tive in nature. He cited the example of having assessed a man for sex-change surgery only to discover that a female identity within the undi- agnosed DID patient was the driving force behind the pursuit of the operation. Rivera (2002) also mentioned cases of undiagnosed DID in transexuals that resulted in post-surgical psychological decompensation.
The World Professional Association for Trans- gender Health’s 7th Edition of their Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (WPATH, 2011), make clear that these conditions should not be reduced to simple dissociative explana- tions. However, the Standards of Care do explic- itly refer to DID as one co-occurring condition for which gender nonconforming clients should be evaluated, particularly prior to sexual reassign- ment surgery (SRS). If confirmed, the Standards of Care assert that DID must be treated before
commencement of SRS. This caution appears well supported beyond the anecdotal case evi- dence noted above.
One study of 64 high functioning transexuals found 10% of the sample scoring above 30 in the Dissociative Experiences Scale, which suggests the presence of a dissociative disorder (Walling, Goodwin, & Cole, 1998). Since the mid-1980s, rates of regret among individuals who pursue sexual reassignment surgery (SRS) have varied from 10% to 30% (Olsson & Moller, 2006). Recent reports suggest that while SRS often improves sexual functioning and gender dyspho- ria among post-operative transsexuals, it may not remedy high rates of morbidity and mortality among these individuals (Dhejne, Lichtenstein, Boman, Johansson, Langstrom, & Landen, 2011; Klein & Gorzalka, 2009). Prior longitudinal SRS outcome studies may not have had follow up periods of sufficient duration (at least a decade) to detect the persistence of such elevated risks.
Implications for Treatment
These apparent psychodynamic considerations may be especially important in light of the fact that relevant practice guidelines provide little direction in understanding or untangling the dis- sociation and same-sex attraction/behavior inter- action. Although the WPATH Standards of Care (2011) explicitly mention DID as a possible co- occurring condition with transgenderism and transsexualism, the Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients make no mention of dissociation or dissociative disorders (American Psychological Association, 2011). In fact, these guidelines make no mention of sexual abuse, only one mention of physical abuse, and only mention trauma in the context of discussing minority stress. Similarly, the Guide- lines for Treating Dissociative Identity Disorder in Adults (ISSTD, 2011) fail to address the topic of sexual orientation. The reasons for such contrasts between and omissions within these professional guidelines are not clear; nevertheless, clinicians faced with patients such as Gina need to be famil- iar with these guidelines as well as the controver- sies involving sexual orientation change (American Psychological Association, 2009; Jones, Rosik, Williams, & Byrd, 2010).
Thus, while somewhat dated, the literature ger- mane to DID and same-sex attractions and behav- iors cannot be easily dismissed. The psychodynamics of opposite-gender identities in DID provides clinicians with some beneficial
282 CASE STUDIES
insights for psychotherapeutic treatment, particu- larly where unwanted same-sex attractions and behavior have been reported in traumatized patients who evidence a significant degree of dis- sociation. Some of these are described below in no particular order of importance.
Sexual behavior as a secondary issue Dissociative and traumatized patients may be
very focused on the unacceptability of their same-sex behavior and attractions, especially if they come from conservatively religious back- grounds. While it may be tempting for thera- pists who are Christian to place an initial focus primarily on the patient's sexual behavior, this would be a mistake. The psychodynamics of opposite-gender identities illuminates the reality that in these cases same-sex sexual behavior is often formed as a psychological adaptation to cope with trauma. Therefore, while the thera- pist sometimes will need to assist the patient in establishing boundaries on sexual behavior, the goal of effective treatment cannot simply be behavioral management. Unless the underlying, trauma-driven dissociative distortions in cogni- tions and self-perception are addressed, the psy- chological coping mechanisms that may give rise to the unwanted same-sex behavior and attractions are likely to continue to perpetuate them. The goal is to dissolve the dissociative barriers between identities through the process- ing of traumatic material and correction of relat- ed cognitive distortions. Ross (1989) observed that opposite-gender identities can be integrated with no disturbing effect on the patient's prima- ry gender identity.
Trust is a must It is impossible to stress how important the
establishment of safety and trust is in the treat- ment of DID related unwanted same-sex attrac- tions and behavior. This insight is related to the previous one in that religious moralizing by the therapist regarding same-sex behavior will only serve to hinder the patient's ability to address it by reinforcing the defensive functions of the opposite-gender and other identities. The conser- vative Christian patient, in particular, is quite like- ly to have already internalized condemnatory messages regarding same-sex behavior, so that an early treatment goal is to facilitate the develop- ment of a strong alliance by providing a safe, nonjudgmental environment. Same-sex behaviors and attractions can be therapeutically examined more from a position of functional curiosity than
moral evaluation. Furthermore, in the treatment of DID, the therapist has to establish trust with all of the identities, and to favor one may raise the ire of others (MacGregor, 1996).
Thus, a host identity may have rigid convictions against same-sex behavior, but an opposite-gen- der identity may not even perceive the sexual behavior in this manner and consider the thera- pist's strong affirmation of the host's perspective as a threatening collusion. Even in non-DID patients with childhood trauma, it will benefit the therapeutic relationship if therapists keep in mind that what they say about the patient's same-sex behavior may well be received by ego states who have dynamic functions similar to what has been noted above. The art of therapy in providing DID patients with a safe and healing environment lies in the therapist's ability to walk that fine line between the unproductive indulging of identities in their perceptual distortions and the unintended reinforcement of dissociative defenses in the pro- vision of reality-based boundaries.
Griefwork Opposite-gender identities, as is the case for
most other identities in DID, are trauma-driven. Once safety and trust have been reasonably established within the therapeutic relationship, the gradual work of diminishing dissociative bar- riers and promoting integration of identities begins. As dissociation gives way to re-associa- tion, the confronting and processing of traumatic material typically brings patients face-to-face with the unvarnished reality of their abusive childhood experiences. This integrative task is facilitated and brought to completion by ongoing griefwork (Howell, 2002). For example, by becoming aware of the traumatic material of other identities and the perceptual incongruity of his male gender, Alex came to recognize his pro- tective function and began (along with other identities) grieving the harsh reality that Gina had been left utterly unprotected by her mother and other guardians.
Final Observations
MacGregor (1996) astutely noted that, "Perhaps more than any other disorder, MPD [multiple personality disorder, now termed DID] suggests the plausibility of psychoanalytic concepts" (p. 389). Because I believe this to be absolutely accurate, I have taken somewhat of a risk by examining same-sex attractions and behavior through the lens of DID and opposite-gender
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alternate identities. It is evident from this analy- sis that there is a dearth of literature addressing this topic and that what literature there is has evolved in ways that mirror the cultural shifts regarding the psychological status of homosexu- ality. That is, the earlier analyses seem more open to the application of a dissociative trauma model in understanding the origins of some same-sex behavior and attractions. By contrast, more recent discussions appear to discount their potential etiological significance. Without arriv- ing at any peremptory determination on this sub- ject, I want to close by making two observations that I believe will ensure a scientifically responsi- ble treatment of the topic.
First, responsible theorizing about the role of opposite-gender identities in same-sex behavior and attraction has to acknowledge that such extreme dissociative dynamics are likely to be involved in only a relatively small percentage of individuals with such experiences. Case exam- ples such as that of Gina have a primarily heuris- tic value for the development of hypotheses and cannot be assumed applicable to other cases in the absence of further scientific evidence. Insights gleaned from DID sufferers may well have a broader relevance to non-DID patients who report childhood trauma and same-sex behavior, but even then one has to be careful not to over generalize their relevance in understand- ing the origins of behavior associated with minority sexual orientation. I am familiar with cases of DID where the post-integration sexual orientation identified as homosexual, so it should not be assumed that the healing of trauma neces- sarily results in a heterosexual adjustment.
That being said, however, the other danger to avoid is to deny altogether the psychodynamic implications of opposite-gender identities in comprehending trauma-driven contributions to the genesis of some cases of same-sex behavior and attractions. The more recent writing on this subject appears to discount such possibilities as a perquisite for being scientifically credible (Howell, 2002; Rivera, 2002). From my perspec- tive, however, a scientifically honest curiosity into this phenomenon that is not constrained by sociopolitical considerations would be eager to undertake research and theorizing about it. Yet a fairly pervasive silence on this intriguing topic currently exists within the dissociative disorders and human sexuality fields. Perhaps this is occurring out of an understandable desire to not add to the stigmatization of sexual minorities by
linking childhood abuse to the development of even some instances of homosexuality. If this is accurate, then it must at least be recognized that the resulting political climate surrounding the social sciences may be hindering the profes- sion's ability to alleviate the suffering of some individuals who present with histories of trauma and unwanted same-sex attractions and behav- ior. I sincerely hope the future will show that preserving human dignity and relieving human suffering need not be mutually exclusive aims in addressing the intersection of dissociation and same-sex experiences.
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Author
Christopher H. Rosik, Ph.D., is a psychologist and Director of Research at the Link Care Center in Fresno, California. He is also a member of the clinical faculty at Fresno Pacific University. His areas of interest include missionary and pastoral care, dissociative disorders, human sexuality, and the philosophy of social science.
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