A Different-sex Twin Considers Her Sexual Identity


Vassilis Maoutsos M.D.

Some theoretical points

In the psychoanalytic literature there appear to be relatively few reports dealing with twin cases. In view of the high incidence of neuroses and other psychological disturbances among twins it would be expected that more often twinship would have been described as a major cause of psychosexual developmental defect. According to Leonard (1959) “in the case of every twin whose analysis has been reported, the twin relationship was considered the prime reason for that individual’s emotional disturbance”.

This apparent misrepresentation of twin cases might be due to the fact that one in every 88 of the adult population has a twin alive instead of the expected one in 60 (Sym: 1979) that should have been the case if the other twin had survived birth or, more important, during the first years of life. This is to say that among this particular group of twins those who come for analysis may well treat the other sibling as if he/she has never existed or has never been influential enough in the patient’s life. Although this may be true in some cases it is probably not the rule and twinship should therefore be taken very much into account even in cases when the other twin died early in life. In fact, it is suggested in this paper that the basic psychodynamic make up of twinship and the very early stage at which it is formed in one’s life makes it unlikely that the “other half” – as often twins like to call their twin sibling – has been as unimportant as it is claimed to be the case.

In the majority of twins, however, with both of them alive, similar denial mechanisms, important as they may be, do not appear as the most prominent features. In these cases the feelings are immensely more complex. In a detailed study of identical twins D. Burlingham and A. Barron (1963) refer to what they call “copying games” of the twins; their “love relationship” as well as their aggressivity towards each other; their “intense reactions” to separation from one another as well as their tendency to form “a team” of the two of them whenever one is confronted with a difficult situation.

One might point out that similar observations could equally well have been made for any two siblings of approximately similar age. So in terms of psychic dynamics the above findings do not necessarily constitute sufficient reason to make twinship a special clinical condition. Siblings do identify with one another to a certain extent and they react violently when their own individuality is threatened. If that is the case then it could be argued that twinship is at best different in degree only from any other sibling relationship and at worst it needs no special mention whatsoever.

Twinship, however, goes well beyond that and it is by no means an exaggerated form of an ordinary sibling relationship. In another of her studies on twinship D. Burlingham (1945) makes the point that most people at some stage during their lives have had a period when they enjoyed the fantasy of having a twin sibling. This remarkable observation throws some light on the jealousy that people appear to have towards twins in general. The way that this is commonly expressed is through enormous “admiration” and “love” that adults show for twins and their mothers; it is almost as if they themselves would have liked to be in the twins’ position. In fact, children too have a similar spontaneous reaction when they come in contact with twins, and most certainly brothers and sisters resent their twin siblings who to them appear to enjoy a superior kind of friendship than they can ever have themselves.

In reality though, twins and all those who care for them face many problems which makes their position less enviable. However, the above attitude which M. Leonard likens to “mass repression” has a significant impact upon the mother whose relationship with the twins matters more than any other with the exception perhaps of their own relationship. For a mother who lives in straitened circumstances the bearing of twins will be a great shock, even if it is denied by her environment. On the other hand it is true that there is a degree of narcissistic pleasure for the mother too; everybody expresses interest in her capability of producing two children at one go and her exhibitionistic needs get greatly gratified.

These relatively minor positive aspects of the relationship of twins with their mother are not sufficient to prevent the relationship of the mother with each of her twin children separately from being affected in a negative way to a greater or lesser extent (D. Burlingham, 1946). In the case of identical twins this takes the form of the mother even confusing the twins. With twins of the same or different sex the effect upon the mother is eventually the same even if a first there is no confusion of identities of the children. What has to be appreciated is that the mother in one way or another has to identify with only one of her twins and to reject (at least temporarily) the other one if she is going to go through her own “maturational crisis” (G.C. Bibring, 1961) without too much personal damage. What intrapsychic difficulties of her own the mother may have been going through is often indicated by her expressed wish that she would have liked to have treated her twins alike or equally but somehow for some reason she was never capable of doing so. This is also the complaint that twins themselves express; namely that they have been let down by their mothers. This, important as it may be does not explain enough of their particular psychopathology. So, if twinship is more that an exaggerated form of siblinghood – as it is suggested here – then it is important to look at the most basic intrapsychic conflicts that it represents for the individual twin.

In 1920 Freud made a passing comment which gives a clue as to what these conflicts may have as their nucleus. He wrote: “I once knew two twin brothers both of whom were endowed with strong libidinal impulses. One of them was successful with women and had innumerable affaires with women and girls. The other went the same way at first, but it became unpleasant for him to be trespassing on this brother’s preserves and, owing to the likeness between them to be mistaken for him on intimate occasion so he got out of the difficulty by becoming homosexual. He left the women to his brother and thus retired in his favour”. What he describes here would have been of no interest if he was referring to a typical case of homosexuality of Oedipal origin. Then the father would have been expected to be the main protagonist in the conflict that the individual experiences. This is not the case in the above quotation; instead the Oedipal father is displaced by the twin brother who thrusts aside the father. This form of Oedipal conflict is a very common one among twins an it is often accompanied by homosexuality. Other authors have also made reference to it. For instance, D Orr (1941) says that “in the face of sever conflicts between forces calling forth his individuality and other forces cementing his twinship, and between drives to remain passive and other drives to assert aggressive masculinity, the patient compromised by developing a general dependent, unconsciously homosexual personality with many sadistic and passive oral traits”. As the main expressions of this patient’s conflicts, he goes on to formulate the following questions which are also relevant to the case to be present in this paper: “Am I an individual or am I only half an individual”, “Am I a boy or am I a girl” and “What happens if I excel my twin and what happens when my twin excels me”. While the origin of the first question is archaic and related more to the second main aspect of twinship to be discussed later, the other questions constitute part of the Oedipal dilemma in a modified form.

The unconscious replacement of the same sex oedipal parent in the analytic situation by the twin sibling is perhaps an important characteristic of twinship. This is so because it can decisively determine the respective role of each twin in the relationship. In the case of male twins it results in what Freud describes in the above extract. With one female and one male twin – which is more relevant to the case for discussion – the roles get reversed, especially when the female one was born second with all the psychological implications of such a disadvantage.

This type of Oedipal homosexuality in twins is not perhaps as simple as it appears to be assumed from this description, which seems to be taking for granted that pre-Oedipal developmental stages have been negotiated reasonably well. This cannot be true in the case of twins. Already in the above quotation mention is made of “passive oral traits”.

Traits of this character would be expected to have a decisive effect upon later developmental stages if they are strong enough. For all those practical and psychological reasons that were mentioned earlier it is reasonable to imagine that oral frustrations cannot be uncommon in the bringing up of twins. But there is also another reason that orality becomes such an important aspect in the analysis of twins. It has to do with the extended periods of time that twins tend to spend together in very close proximity to one another from the very early days of their life. Leonard points out that from approximately the fifth or sixth month onwards the twins are sufficiently aware of each other so that being together seems to have a quietening effect. The constant close contact that they have is of particular significance because of the way that by visual means it interferes with the oral stage of incorporation of the mother. Normally oral incorporation is a necessary element of the primary identification process (S. Freud, 1921) and excessive visual incorporation endangers this process. Some of the negative effects of this interference are language disturbances, loss of body boundaries and self-identity and incomplete object libidinal cathexis, from which twins so often suffer.

The main inhibitory effect of this “inter-twin primary identification” as it has been named is that it has the strong tendency to be self-perpetuating; once it has started it inhibits progress toward communication with individuals other than the twin sibling and thus the development of object relations in particular, can be hindered considerably. The way that this phenomenon appears in the transference situation is remarkable.

Those oral aspects of twinship together with their accompanying ego disturbances is the second major feature that one would expect to find in twins that have been reared together. In order to describe it E. Joseph et al (1961) uses the term “twinning reaction”. According to him it consists in: 1) mutual inter-identification and 2) part fusion of the self-representation and the object representation of the other member of the pair.

The twinning reaction does not depend upon the sameness of sex in the twins. Different-sex twins are affected by it as much as same sex twins. However, with different sex twins an additional factor has to be taken into account; to the genitals of the male twin as long as we concentrate on the female one (A. Maenchen). In the analytic situation this amounts to a fantasy that the female twin is in the possession of a penis. For if there is to be twinship equality demanded by the very process of intertwin primary identification then it must operate in such a way so that an illusory penis has to be created, presumably through oral means in the fashion described earlier. In clinical terms the existence of such an illusory penis raises enormous defenses that may be proved the most critical factor of analytic success or failure. The female twin denies her femininity by making extensive use of projections and rationalizations.

With this psycho-dynamic profile the girl reaches the Oedipal age when equality as such cannot be maintained any longer; she has then no alternative but to compete with the brother on the basis of an illusory penis rather than envy of his penis. It is then by no means unexpected that sex identity can be such an important problem among twins.

Case Presentation
The case that I am presenting here is of a 28 year old Catholic woman of no particularly religious background. Her father is a medical doctor who was a general practitioner until ten years ago when he gave up his practice after a stroke. My patient feels that she has to blame herself for this. Besides his love for soccer and horse riding he also had an inclination towards excessive alcohol drinking and a dislike for his mentally suffering patients. Her mother, for whom Miss A – as I will call my patient – had made mention only on a few occasions during the first year or so of her psychotherapy has been presented as an almost non-existing person. Lately this has changed and Miss A has suddenly come to appreciate her mother as a painter and director of theatrical productions when she was a child. Miss A has two brothers, two sisters and a twin brother, all of them older than herself. She scarcely ever mixed with her brothers and sisters apart from her twin brother with whom she had “a very special relationship” which would perhaps be described as a symbiotic one. They went to the same school – different from that of the other siblings – she wore his clothes and she was often called by his name because of their similar looks. The whole family in a way was divided into two groups: One led by the father, which included the twins and the home help – Miss Mary – and another one led by her mother. Miss Mary, in fact, had undertaken the upbringing of my patient but not that of her twin brother, this was the responsibility of mother and on many occasions during the sessions I have felt that this was the only contact that the two groups had between them. For as far back as two and a half years of age she had vivid memories of her mother taking her twin brother away to feed him in private and herself staying with Miss Mary and feeling very miserable indeed. When it was time for her to be fed she was never fed by her mother. She remembers Miss Mary shaking in front of her eyes a bottle of milk and threatening to drink it while she herself was scared that it would hit her on the head. She could see the connection between the incident and her very strong fear at that stage in her therapy that I had been forcing her to accept my interpretation or to lie on the couch; things that she had passively accepted until then.
But beside her oral anxieties connected with Miss Mary she had also invested her with enormous power which Miss Mary was only prepared to use for those that she loved and in the following instance, for Miss A’s father. Her father came home drunk and he asked for Miss Mary to follow him into the bedroom rather than his wife. Later on in the same day her father was in a good mood which indicated to Miss A that it was because of Miss Mary who had somehow made him well. She then connected the “private intercourse” between her mother and her tine and fragile twin brother with the intercourse that had taken place between Miss Mary and her father. Her fantasies were clearly oral and this was manifested in her fantasy that I could also make her better if only I wanted to. “I am sure” she used to say “that one day we will have sex together. I cannot see why this should not be allowed in psychotherapy”. When I pointed out to her that we did not know what kind of sex her father had with Miss Betty, she emphatically pointed out “I am sure it was oral sex” and then she added “Why! Is there anything bad with that?” As she got no reply from me she added “Are you one of those sex-maniacs that do not accept oral sex; That you only want vaginal sex? I am not going to have that”. When I replied that she would never agree to anything less than her twin brother had, she broke into tears.

Miss A had a characteristic relationship with her twin brother. The typical part of that relationship was first that from the age of two and a half years or so they had mothering from different “mothers” and secondly that she was in charge of the relationship. Both these aspects became obvious from the early stages of her therapy but we had no idea why that was so, especially if one considers that she had been born second. On the other hand, both twins belonged to the same “group” in the family and in many ways their symbiotic relationship was most typical. She was feeling sorry for her twin brother who was “a little backward educationally and he was bullied by other children” so that she had to protect him all the time. She had to teach him the school-lesson and in a way she feels that she spent all her childhood caring for her twin brother. Everybody recognizes her superiority intellectually and athletically. For that reason her father, for whom she was the favourite child, bought a horse for her which could not be used by anybody else but only those two. This however, seemed to have precipitated in a way a change in her brother: he suddenly became good at horse riding and as far as she is concerned almost everything else. They were twelve years of age at the time and while he was gaining height she was remaining fat and short. She feels that she has almost remained static since her adolescence and she attributes that to the rheumatic arthritis that she had at that time; this should have been her father’s responsibility but he never believed her when she complained. She often brings to me a number of somatic complaints like vaginitis, headaches, and even falling out of her hair, all of them related to that period in her life, and she demands that even if I cannot treat her for these complaints I should not think, as she feels that her father did, that they have any other meaning but are real physical symptoms. The control that she tried to exercise upon my thinking was the same that she felt that she had over her father from a very early age. This collapses somehow, when her twin brother suddenly started, during adolescence, growing faster than herself. Her physical symptoms intensified but her father refuses to examine her. There was a precise correspondence of these feelings in the transference: There was then one person who agreed to examine her physically and to see why she was not feeling well; that person was her father’s senior lady partner. She had immediately felt better after that. Similarly before she came to me she had been assessed by Dr Tonnesmann and this she wanted to be repeated. I had pointed out to her that these seemed to have been perhaps the best contacts that she had ever made with people and they were both with female individuals. She agreed with that and she added that she had some other “unique experiences” with a girl friend some years ago. In that relationship it was the oral element that was determining the relationship. She was passively accepting her friend’s cuddles but she was angrily biting her “beautiful stiff breast”. She had felt very guilty at the time and she admitted having the fantasy of hurting me while having oral sex with me. By interpreting her apparent confusion between her friend’s nipples and her brother’s penis, in whose place I was standing in the transference, she felt great relief.

The whole area of oral anxieties emerged as the main problem in her psychotherapy. The problem consists not so much in the nature of her anxieties but in their form. What I mean by this could perhaps better be described in terms of transference and counter-transference: In the transference situation I could often be the depriving mother who always gave her less than she needed or I could be the idealized father or the hated father who rejected her when she was most in need of him. These were fluctuations taking place quickly during the same session; and they showed how unstable her object-relations had been. I could be good or bad, feminine or masculine, handsome or ugly, many times. For instance there was an occasion when, after she had described a painting of hers in which I was in a prominent position, she suddenly started insulting me and walked out of the consulting room. She could not stand me being where she herself had put me a few minutes earlier and she immediately tried to demolish me again from that position. To interpret this and other similar incidents, I was helped by my own counter-transference where I was often feeling lost as to where I stood with her because of the fluidity of her perception of myself and her confusion, which eventually became my own confusion. Then I found that all these figures in her life – father, mother, Miss Mary – were really only need-fulfilling part-objects to be exchanged one for another. They were really used as aspects of another object, namely her twin brother, who after a certain point in her therapy became the main protagonist of her unconscious life. It is this aspect of her psycho development that I would like now to stress more.

During the first year or so of her therapy Miss A was quite keen to talk about her family but more than anything about her weak twin brother whom she loved so much and whom she had “made into a chemist almost in spite of his alleged stupidity and incompetence”. There seemed to be a general consensus in the family and also outside that the twin brother was mentally handicapped to some extent. This was the reason, according to her, that although he managed to start reading chemistry he never qualified. They discovered in the University how little he could do and everybody agreed that he should not have tried in the first place. There were many obvious discrepancies in what she was saying: how for instance, could he be so stupid that he needed special care as a child and was still able to enter the University in the first place? How suddenly at the age of twelve did he start horse riding and how could he work as an assistant chemist in pharmaceutical company and be promoted to the manager’s post? These were not questions to be put to her in order to face her projections in that phase of her psychotherapy as she was not ready yet to take any of it but they were surely relevant to the way that I was seen in the transference. She denied all that time all my transference interpretations as long as they bore any relevance to her feelings for her beloved twin brother. For everything the responsibility lay with her father and her mother: The father because he never gave her proper medical care and he did not allow her to study medicine and her mother because she was not interested in her. There was absolutely no question about her feelings for her brother; they were benign feelings; so were her feelings for me as long as I interpreted myself in the transference in relation to her mother, Miss Mary and father only.

Another area that she was rigorously defending was around the events that precipitated her self-referral to the B.A.P. When I first met Miss A she said that what troubled her was that she could be very aggressive towards female students in the Art-Therapy College where she was studying and that there had been two incidents that made her think that she could not carry on as she was and that she needed to understand herself better before she finished her studies, which she had interrupted at that time. As it turned out, one of these two students had a long-standing friendly relationship with Miss A since the time that they were at school together. In the College this friend of hers showed exceptional artistic talent and she also developed a lesbian relationship with the other student whom my patient had unpredictably kicked during a psychodrama session. For a very long time Miss A denied the artistic talent of her friend and also she tried hard to compete, with some success, but on the whole she felt that she was failing. In spite of that she saw her friend as weak, perhaps without intelligence and naive; a person whom she really had to protect. She saw the other student as lacking warmth and very aggressive, therefore, she had to be afraid of her. She was competing with her, too, not in artistic work but in the engine power of the motor-bike that each one was capable or riding. She always came second and she squarely attributed that to her small stature. She finally developed a homosexual relationship with her weak friend which lasted only for a short time. She could have had a relationship with the other student, but she did not want this being afraid of her own intense anger towards her. What was important in that relationship and in another similar one later was the excessive amount of time that she spent “watching” the other woman’s body which she found fascinating. She then painted miniature pictures of two people, one of whom looked like a woman and the other like a man, embracing each other. In many of these pictures I was also present watching them. In her association to the pictures she always confused which of the two she was; most often being the male by a slip of the tongue or a joke that she was prepared to make. However, she was never happy with her paintings because I should not be watching them. Instead she said, I should be in bed with her “if not having sex, at least being together watching each other”. I had not interpreted this material for some time until one session when she brought a dream. From this dream we understood the reason why she was so unhappy in her artistic work: In the dream we were both lying in two different beds while others were around us having something like a party. Among them were her parents. Suddenly all the people disappeared and we remained in our beds with only her mother watching us and ourselves staring at each other.

When I interpreted to her the meaning of this dream as a memory of the past with myself being her twin brother in infancy rather than anybody else, she became terrified and ran into the toilet in the middle of the session. The “weak” friend had also been a twin brother to her while the “aggressive” one was her mother.

However, it was by now clear to me that our relationship was primarily based on her very early relationship with her twin brother which for some reason was experienced by my patient as moving from a symbiotic one to a protective one at around the age of two and a half. Now it was easier for her to accept my position as a twin brother to her. She admitted that she all along wanted to help me as a student of the B.A.P. in my studies, which would have been a sacrifice similar to that she felt she made for her twin brother. At the same time, however, she started missing sessions. Fortunately enough, the first eighteen months of her therapy had passed and she dad managed to pass her final exams as a qualified art-therapist. But the realization that her relationship with her twin brother could have been anything but perfect really shattered her. She bought a bigger motor-bike to compete, more successfully, this time with her boy-friend with whom she had by then managed to keep a relationship going for over a year in contrast to all her previous relationships which had lasted no more than a few days or a week at the best. She wouldn’t leave off riding her powerful motor-bike in spite of her continual accidents. She often insulted me and she said that I was right in comparing myself with her twin brother because it was now obvious to her that my intelligence was not any greater than his. She even followed me to a psycho-analytic seminar in the University building which I interpreted as her wish that her twin brother should not have good experiences on his own.

Her frequent acting out was at times serious enough for me to wonder if her ego functions were able to sustain the psycho-therapeutic process and I therefore questioned whether I should have waited longer before I touched upon her relationship with her brother. On the other hand I knew that at some point she would inevitably have to face her rage against her twin brother around which she had built all her projections and denials. That this should happen in the context of the negative transference was inevitable if collusion between the two of us was to be avoided as a long-term situation.

During the next stage of her psychotherapy a much more realistic assessment of her twin brother as the favourite child in the family emerged. The following dream played a decisive role in that assessment. In her dream she was lying between the front and rear seats in a car and those sitting in the rear seat were resting their feet on her. Then, everybody had left the car and she was locked inside it on her own. Without knowing why, she insisted that the dream had to do with her twin brother and also myself who had just returned from holiday. She associated that during my absence she often thought of myself being involved in accidents and she visualized me in hospital’ she even painted a picture of me being there. I asked her if she remembered her twin brother ever being in hospital. She started crying, something that she had only done once before, and she said that when they were two and a half years of age her twin brother swallowed a toy for which he had to have a major surgical operation as the toy was too big to pass through the digestive canal. During his stay in hospital she was never allowed to go in the ward and when the rest of the family went to visit him she stayed in the car looking at her brother only when her mother took him to the window for her to see him. The memory of that episode was very important for her because she could now put all that had happened between herself and her mother after that age into perspective. Her period of confusion and disturbance after that dream ceased although she continued having accidents with her motor-bike.

Her attendance became much more regular and her work with mentally handicapped children, which for some months had suffered, was now back to normal. More importantly, her displaced anger onto myself went back where it belonged – to her twin brother. “I thought that he dad died” she said “and for years after I wished that he was dead”. She remembered when they were later playing dead and she tried to bring him close to the traffic whenever it was his turn to be the dead one. What has also changed since she had that dream, from a situation of no relationship whatsoever to a realistic relationship, is that between herself and her mother. After years of very little contact indeed between them they now ring each other regularly.

Then her twin brother got married. At first she would simply not believe that it could be true. At the marriage reception she was sick several times and she started dreaming of being in bed with her sister-in-law. Long periods of silence started making their appearance and she was competing with me about things like who would talk less in the session or if she should lie on the couch anymore. Her main preoccupation became the next motor-bike that she was planning to buy and how much bigger it should be compared with that of her boy-friend. She went around all the showrooms of London and in the end she got one that was so big that she had to sell it later on. She felt that I was so much like her twin brother that she could not continue with me because it was impossible to understand how her twin brother could be a man. She therefore wanted to go to a female therapist who would be like herself, but capable of understanding her like a Finnish boy-friend that she had when she was eighteen years old. He was shy and introvert like the “weak” art student and that excited her so much. Here once more she was expressing her very deep doubts about her sexual identity, as well as the sexual identity of her twin brother. In effect, what she was saying was that the male one of the two was herself and not her brother, and it was difficult for her to see me in any other way but as female.

The marriage of her brother reminded her of the fact that that might not be so. The time seemed now the right one for this material to be interpreted accordingly but the risk of her starting acting-out her masculine fantasies was always there. At this time she kept changing flats and she was trying to get rid of her boy-friend while at the same time she was seeking actively female company. She felt that it was my fault that she could not arrange her life as she wanted to because, like her twin brother, I seemed to have decided “that a woman must be married and have children” and she did not think that there was “such a thing as a woman or a man”.

That she also wanted a female therapist was very hesitantly accepted even when there was little doubt about it. To separate from me was as difficult as it was to separate from her twin brother no matter how much she wanted to. I saw this as being the result of the “primary intertwin identification” which was created at such an early pre-verbal stage in her development that she could hardly talk about it, thus her prolonged periods of silence. She later, however, started feeling that it was her right to claim that she was as much a man as she was a woman. She constantly lived the experience of having a penis and after her brother’s operation she grew up with the fantasy that her twin brother might after all have no penis at all. This is why she used to say that when as children they had a bath together she never remembered having seen her brother’s genitals. (Freud, 1927). This probably was related to the time when she saw her brother’s abdominal scar following his operation and she thought that during his stay in the hospital they had cut off his penis. So, when he recently got married she, apart from feeling very upset, wondered how her sister-in-law had married a man who she was convinced had no normal sexual organs and was therefore unable to have children. Then she heard that the sister-in-law was pregnant, she could not believe that she could have a baby by her brother. When her sister-in-law actually gave birth Miss A felt compelled to go to Belfast to find out if the child looked like her brother at all. In the event, she felt shocked to see her nephew looking like herself. She did not even touch the child. It scared her to visualize herself as the father of the child, but later her visit to Belfast proved to have a very reassuring effect on her. For if her brother’s penis had visually been incorporated into her own body it was now going back to where it belonged. When I said to her that her trip to Belfast was worthwhile if not for any other reason at least because things between her and her brother were now more clear than ever before, she replied that she knew that from now on they (herself and her twin brother) are two different people who have nothing in common except only that one was born several minutes later than the other and, unfortunately, she was the one who came second. She then herself related to me how differently she saw me now for the first time. I had now become the one who would “protect’ her from her “split self”.

This phase in Miss A ‘s therapy has certainly been a very crucial one. It has also been very difficult for me to handle it at times. In the end, it seems to have been the most rewarding one too. Before Miss A made conscious her immense envy for internalized twin brother she was in a state of psychological hermaphroditism which she had to defend vigorously. As the result of her being a twin and having experienced certain traumata in her early childhood this was in excess of any similar normal process. However, her fantasies underwent maturation so that as an adult she felt that she had hermaphroditic genitals. Her femininity then became of little importance to her. After the marriage of her twin brother all this had to change to adapt to the demands of reality. This was not an easy task. Under the pressure of facing in the transference a non-feminine twin brother she became totally confused as to her sexual gender and she demanded that she had a female therapist. That became absolutely necessary to her if she was to preserve her masculine identity intact. She interrupted her therapy for five weeks and she even wrote to the chairman of the B.A.P. claiming that I had not paid enough attention in the past to her “need to bite”.

Before I complete my presentation I must refer to a dream that she had after she came back from Belfast which was very important to the preceding period of negative transference as well as to its positive outcome: In the dream she had seen herself being born and her mother was holding another baby in her arms. She had no associations to that dream at all. I pointed out to her that her silence indicated how difficult it was for her to talk about the unspeakable. She responded by taking the pillow and covering her face. The following day she reported that she had started working on a painting in which she gave birth to herself. The day after she lost that painting from the back of her motor-bike. She did not like it, she said, and she started to work on another one which she tore up for the same reason. This was repeated several times. Then I reminded her of her dream and of the fact that she denied its significance by trying to reproduce it on paper with a meaning which was different from that of the dream, which showed her deep anxiety around the facts of her own birth and her brother’s birth. When we met for the first time after the period of interruption of her therapy she said that she had completed a new version of her painting. Her mother and not herself was this time giving birth to herself while another baby was lying on the floor and I was watching from a distance all that was happening. I remarked that my presence ensured that her birth was indeed separate from that of her twin brother and that after all she was now a complete and separate individual in her own right.
The fact that she now for the first time wants to have a child herself and to get married, no matter how much it frightens her, is an admittance of the loss of her illusory penis and at the same time of a discovery which she calls “femininity”, and which she sharply differentiates from something else which she calls “sexuality”, which in many ways still scares her.

I have described here some aspects of Miss A’s analytic psychotherapy which has lasted just under three years so far. The initial phase of that period was characterized by an intense positive transference which at times seemed to be followed by a loss of reality and could best be described under the concept of transference neurosis (S. Freud, 1920). Miss A was ready to accept my interpretations and in many ways she seemed to be making progress. This, however, at some point stopped. She began to sexualize all that I was saying and she even brought to me a lot of dream material in order to satisfy my needs as a student. She had always been conscious of that as she admitted later. Her very important Oedipal anxieties could now be discussed freely but with minimal affect for most of the time.

Things somehow started changing when her relationship with her mother came into the session. It had taken her at least a year before she was able to talk about her mother as a real person, and it was easy to see the persecutory character (M. Klein, 1952) of the relationship.

In the counter-transference, however, I had detected clear signs of collusion with her from around that time. She was in control of the situation. The “love” for her twin brother could not make sense either. When I became aware of my feelings as a twin brother whom she tried to protect from his weakness a lot of things changed. The collusion was a kind of fusion between us in the sense that is described by E. Joseph et al. The phenomenon of the twinning reaction as a pre-verbal and pre-Oedipal situation, in her case almost superseded the relationship between mother and baby. I would go as far as to say that the visual aspects of her early relationship with her twin brother altered the natural process of oral incorporation of the mother to the extent that “watching” became more important to her than any other aspect of her homosexual or heterosexual relationships. This is probably related to her artistic talent too.

Because of the difficulties in establishing identity and body boundaries that the twinning reaction involves, Miss A became fairly confused as to what gender she was and who she was as a person. The traumatic event of her brother’s operation facilitated the fantasy cognition as to who was the boy and who was the girl. All her defenses were developed around that area. Her environment did not help her in this respect either. Her father used to call her Paul instead of Pauline and he used to take her to the pub and to make jokes with his friends about her masculine preoccupations. On the other hand he did not allow her to study medicine through which she might have sublimated some of her need for an illusory penis. Without doubt her dreams and in particular those that precede the two crises during her treatment made a great deal of difference in the process of her therapy. The marriage of her twin brother helped her through reality testing, to start separating from him as an individual.

As I have tried to describe in this paper all these events have contributed to a process of achieving separation from her twin brother and to her own difficult development as an independent person.

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