Gender Identity Disorders in Boys: A Complemental Series? Martin A. Silverman, M.D. In 1964, a year before I returned to the United States and began my psychoanalytic training, I was serving as a psychiatrist in the United States Army in Frankfurt, Germany. At that time, I was graciously accepted to participate in a study of psychoanalytically oriented group therapy at the Sigmund Freud Institute fur Psychoanalytische Erziehung und Forschung. Several times a week I sat behind a one way screen with several others observing group therapy sessions conducted by Drs. Hermann Argelander and Klaus Frank. One day, as we were walking down the corridor after our discussion of that evenings group therapy session, I must have looked rather glum. Herr Argelander put an arm around my shoulder and asked what was troubling me. "You always seem to know what to say," I replied. "I sit there and watch and it's only once in a while that I have an idea what might be useful to say to the patients in the group." He smiled and said, "Knowing what to say isn't the hard part. The hard part is knowing what's going on. If you know what's going on, it's not so hard to know what to say." I thought of that experience, a little over 30 years ago, as I began to write this. If we want to intervene in a way that might be useful to children with early male gender disturbances, we need to have some idea of what is going on that is producing the disturbances we are attempting to treat. In the 1 960's, people were beginning to study and reflect upon gender disturbances in young children, boys in particular, in part because of interest in trying to understand the origins of homosexuality. Bieber et al (1962) and Socarides (1968) were among the leaders in this. They expanded upon Freud's much earlier observations of more or less universal but variable, inherent bisexuality in human beings and his hypotheses about the role of early childhood experiences in shaping the final form of sexual interests, attitudes, and preferences. The investigations of Bieber and his associates into the boyhood experiences of male homosexuals led them to the idea that a particular childhood constellation is likely to contribute to the eventual emergence of at least one type of homosexuality in adulthood. This consisted, they concluded from their research data, of three things. The first is a mother who is experienced both as sexually seductive and as posing a threat to them and to their masculinity. The second is a father who fails to provide needed balance and protection from the mother's powerful influence because he either is withdrawn or absent or he is overly aggressive or even hostile and therefore dangerous in his own right. The third element is a boy who is shy, timid, and so fearful of incurring physical injury that he associates with girls rather than with rough, physically aggressive boys. The confluence of these three elements eventually leads the boy to feel that it is dangerous to be a boy and that it is much safer and much more desirable to be a girl. Socarides, in a series of publications (1968, 1975, 1978, 1980, 1988, 1990), called attention to the disturbances in the mother-child relationship throughout the childhood of his homosexual patients. He emphasized the importance of very early problems in their interaction, especially as they affect the process of separation individuation in the child. These problems, he indicated, are carried forward epigenetically, so that they seriously affect the way in which the boy experiences and resolves the conflicts and the anxieties attending them during the later genital, Oedipal, latency, and adolescent phases of development. Although further investigation has pointed to a probable multiplicity of constellations and syndromes, with variability both in causation and genesis and in internal psychodynamics, it appears that gender dysphoria and gender nonconformity in childhood are very frequent antecedents of adult male homosexuality (Bell, Weinberg, & Hammersmith, 1981; Whitam, 1983; Green, 1987). Gender identity disturbances in childhood are of interest in their own right, however, and merit study independently of other considerations. The young children who are
brought for treatment tend to be extremely unhappy and extremely anxious, with serious ego and superego disturbances, i.e., with problems that go well beyond the cross-dressing and expressed wish to be a member of the opposite sex that brings them to treatment. Gender identity is a complex matter that appears to derive from the confluence of innate, biological factors and the external, shaping effect of environmental, psychosocial influences. When Donald Hebb was asked 50 years ago about the relative impact of innate and experiential factors in shaping human development, he replied: "The role of constitution is 100%. And the role of environment is 100%." As to constitution, there are innate differences between boys and girls beginning at or before birth. Male and female neonates exhibit intrinsic differences though for the most part they are relatively subtle (Lichtenstein, 1961; Stoller, 1968, 1976, Konner, 1982). Newborn boys exhibit somewhat greater muscle strength (e.g., more head lift in the prone position). Newborn girls show somewhat greater skin and taste sensitivity, more oral searching movements, more reflex smiling, and a quicker response to light flashes. Maccoby and Jacklin (1974) after reviewing hundreds of studies, found very weak evidence of greater tactile sensitivity, timidity, and compliance in girls, greater verbal ability in girls, more assertiveness in boys, and greater visualspatial and quantitative ability in boys. They found no significant, consistently discernible differences between girls and boys in any of the other cognitive and emotional dimensions they looked at. The strongest evidence of gender differences they found was for a greater tendency of girls to develop nurturant attitudes toward infants and for boys to develop more aggressive behavior. And there are enormous differences among the boys themselves and among the girls themselves. Although the studies of Stoller (1968), Money and Ehrhardt (1972), and others point to the possibility that intrinsic, physical factors may contribute to "masculine" and "feminine" attitudes and self-perceptions, it is difficult to demonstrate this objectively. A number of investigators have postulated an intra-uterine as well as a later hormonal "masculinizing" or "feminizing" effect upon the brain. This is observable in various species in terms of certain aspects of behavior, but it has not yet been convincingly demonstrated anatomically in human beings. The first evidence of possible anatomical differences between human female and male brains is an observation by de Lacoste Utamsing and Holloway (1982). When they compared nine male and five female brains they dissected they observed that the rear portion of the corpus callosum, a region which is believed to play a role in transferring visual and spatial information between the two cortical hemispheres, was larger and more bulbous in the male brains. There has been some further evidence of intrinsic male-female brain differences, but we are only beginning to know something about this. The impact of parents and other environmental influences is easier to observe. Parents (and other significant figures) impose their own attitudes, expectations, and conscious and unconscious wishes, demands, and conflict derivatives upon their children from the time of their birth or even earlier. They are certainly influenced by the physical and temperamental characteristics of their infants and young children in this, but their own, subjective attitudes, feelings, and conflicts can easily override what their senses tell them about their children and what they consciously feel would be best for them. And human infants and even toddlers are so helpless, dependent upon maternal care and nurturance, and intertwined in their growing sense of their own selves with their awareness of their mothers and their fathers that they necessarily are powerfully affected by maternal and paternal attitudes and expectations. Although they become aware of their genitals during the latter part of their second year (Galenson & Roiphe, 1971; Galenson et al, 1975), genital differences are not necessarily an important feature of the child's selfperception as a girl or as a boy that forms during the late nonverbal and early verbal period from approximately one and a half to somewhere between three and four years of age, when it becomes more or less stable
(Hampson & Hampson, 1961; Stoller, 1968; Money & Ehrhardt, 1972; Mahler et al, 1975; Meyer, 1982; Green, 19871. During this period of time, the child is passing through the wrenching, ambivalent storms of separationindividuation, with its intense conflicts over aggression and over merger and union versus separateness and autonomous functioning (in the parents as well as in the child). The child also is plunging into the intense conflicts, anxieties, and primitive shame and guilt configurations of the Oedipal stage of development. The form and contents of Oedipal conflicts are unavoidably colored and shaped by the storms through which the child has passed en route to that stage of psychological development. The gender identification that emerges results from the totality of perceptions of self and other, the degree to which there are feelings of safety and security, and all the other aspects of the relationships the child has with the parents and other significant people. It becomes increasingly coordinated with (as opposed to deriving directly from) awareness of genital differences between the sexes. But during the early part of childhood, in particular before the advent of operational thinking at about the age of seven years, children do not have a consistent, clear awareness that the way they are constructed is permanent and unchangeable. Although they are aware they are male or female and that they possess male or female genitalia, they do not necessarily know, firmly and clearly, that they cannot change in those respects. There have been a number of theories to explain gender identity disorders in boys. Which is correct? Can they all be correct to one extent or another? Are we dealing with a multiplicity of syndromes referable to a variable set of biopsychosocial factors in variable combination? The most influential hypothesis for the emergence of the wish of some little boys to be girls, most dramatically expressed in the form of cross-dressing and a dysphoric attitude toward a masculine identity, was for some time that of Stoller (1966, 1968, 1975, 1976). His hypothesis, stated in its simplest terms, is that these boys, usually good-looking, docile, and compliant, are encouraged by depressed, strongly bisexual mothers who wish more or less unconsciously to avoid aloneness and resolve their intense penis envy by establishing their sons as phallic substitutes; they do so by protecting them against frustration and maintaining bodily closeness to them in order to engage in a nonconflictual, unending, blissful symbiosis with them in which their identities would remain continuous and inseparable. The fathers, in this hypothesis, are absent as offsetting influences; at times they are physically absent, but at the very least they are absent psychologically. He attributed the emergence of normal gender identity to the confluence of three factors: awareness of the external genital organs, anatomically and physiologically, the impact of the views and attitudes of parents, siblings, and peers, and a postulated, intrinsic biological force which is hidden from view but nevertheless, in Stoller's view, does exist and is highly influential. The last, a biological impetus to gender identification, became one of the bases of the hypothesis of Money and his associates (Money, 1972; Money & Ehrhardt, 1972) that gender disturbances can arise either from biological (including hormonal) influences or from the effects of early occurring deleterious experiential influences (which they do not precisely define). In this hypothesis, psychological contents and conflicts are secondary rather than primary. The idea of biological determination derives largely from the study of intersex children with hermaphroditism and pseudohermaphroditism. These studies have yielded ambiguous and conflicting results, however. Imperato-McGinley and her associates (Imperato-McGinley et al, 1974, 1976, 1979), for example, have studied groups of boys in the Dominican Republic who, because of a genetic disorder are born with an insufficiency of the enzyme 5-Alpha reductase that is needed to transform testosterone into dihydrotestosterone. They appear to be girls until puberty, when rising levels of dihydrotestosterone transform the appearance of their genitals into a more typical masculine form. Almost all of these individuals are able to shift from a feminine selfrepresentation to a masculine one. As Green (1987) has pointed out, however, (and the same applies to a similar group of Arab boys), certain psychosocial factors very likely play an influential role in easing the transition from feminine to masculine self-
definition: the appearance of their genitalia prior to puberty is somewhat ambiguous; they receive a very high degree of tolerance of their genital ambiguity and a great deal of emotional support from the people around them; and the culture very highly favors males over females. All of this facilitates the shift from a feminine to a masculine identity considerably. On July 16, 1993, it was reported in Science (pp. 291, 321) that geneticist Dean Hamer and his team at the National Cancer Institute had reported on a study involving 40 pairs of brothers both of whom were gay that had led them to conclude that they had discovered a factor on the X chromosome through which gayness was genetically transmitted to them from their mothers. This was hailed as proof that homosexuality in men is biological in origin. Two years later, however, Eliot Marshall reported in Science (June 30, 1995, p.268) George Ebers and George Rice of the University of Western Ontario had unsuccessfully attempted to replicate Hamer's findings and had "found no evidence that gayness is passed from mother to son" genetically. He also reported that the Office of Research Integrity in the Department of Health and Human Services was investigating Hamer's work. Despite these reservations, however, biological factors do need to be given careful consideration, and not only in terms of individual variations in temperament, sensitivities, appearance, aesthetic qualities, etc., that might influence the response of parents and others but also in terms of such posited factors as pre- and postnatal hormonal influences upon the brain of the individual involved. Stoller's hypothesis of nonconflictual gender nonconformity has come into question on the basis of investigative observations which conflict with some of his basic postulates about a blissful union between mother and child, untainted by problems between them. It also is difficult for some investigators to imagine that the intense ambivalence conflicts and identity conflicts of separationindividuation struggles can be bypassed to the extent to which Stoller appears to indicate in his views and to accept the hypothesis that Oedipal conflicts and castration anxieties can be bypassed in the course of these boys' development (Meyer, 1982). A number of current investigators are led by their clinical data to a conflict hypothesis to explain at least some early gender disturbances. A composite, representative picture, is one in which a boy is born to a basically depressed mother whose depression may not always be overtly apparent. A core dimension of her personality is intense loneliness associated with feelings of rejection and abandonment by her own mother. She feels inadequate, deficient, unable to please her mother and win her love. She is hungry for maternal devotion and care, aches for blissful merger and union with her, and consciously or unconsciously transfers her rage at her disappointing mother onto her husband and at men in general for their inability to provide for her what only her mother is perceived as able to provide. She reacts to the birth of a son by investing in him as a means of completing herself, fulfilling her yearnings, and endowing herself with the capacity to feel whole, self-reliant, and protected against the pain of loss, abandonment, and unfulfilled need. At the same time, she is unclear about her own sexual identity and is strongly bisexual, consciously or unconsciously, with intense penis envy and rage against men for their real and supposed power, prerogatives, and privileges. While pregnant, she unconsciously identifies the fetus within her as a penis, and when her baby is born a boy she is consciously and/or unconsciously highly ambivalent toward him. She prizes him as her very special penis-bearing child, her completing and fulfilling self-extension and partner. He approaches, to a greater or lesser degree, being accorded the status of a phallic appendage and a twin-like completing mirror. At the same time, she is enraged at him and his penis for having separated from her in the process of birth, all too reminiscent of her abandonment by her mother, narcissistically and/or more interested in her father or brothers. There is recrudescence and heightening of this rage whenever he makes a new step toward defiant, self-expressive, or willful movement away from her toward greater autonomy and independence.
She also tends to yearn for a girl child who is to be a repaired, idealized version of herself. If a subsequent pregnancy produces another male child, she may decathect her first son and turn away dramatically from him toward her newly arrived, idealized child-penis. Or she may punishingly abandon him in favor of a daughter (with whom she identifies and uses as her agent of revenge, like Mrs. Haversham in Great Expectations), upon whom she lavishes her praise, love, and attention. In any event, she communicates to him from the very beginning that he can remain in her good graces as her loved and cherished child only if he gives up his aspirations to be separate, independent, and different and only if he remains attached to her and takes care of her by fulfilling her vital needs. The boy reacts by developing early and intense insecurity, ambivalence, and fear of being separate from his mother that approaches the unconscious conviction that he cannot and does not exist apart from his mother. The father tends to be passive, helpless, conflicted about his own needfulness and about his own sexual identity. He tends to feel powerless to oppose his wife's insistent dominance of his son's increasing effeminacy. He tends either to be under assertive and under aggressive, or given to intense though short-lived, impotent rages, or to alternate between the two. The boy, who more often than not is sensitive, responsive, gentle, and emotional, as well as handsome and possessing impressive intellectual and/or aesthetic capacities, reacts by acquiescing to his mother's need for him to be one with her, to suppress his own aspirations to be separate and independent, and to devote himself to taking care of her. In doing so, he is reacting in part to his mother's terrifying threats (usually delivered subtly) to withdraw her special love and to abandon him. He is exquisitely aware, albeit largely unconsciously, of her unconscious, hostile, aggressive, cannibalistic inclinations toward him and his genitalia. He becomes terrified of her rage and of his own rage, which he tends to project onto her and, with movement into (distorted) phallic-narcissistic and then Oedipal organizations, onto his image of his father. He oscillates between the wish to guard and protect his separate, independent identity and his penis and the need to sacrifice his independent aspirations in order to hold on to his idealized, all-powerful, all-providing mother. The solution is to effect a compromise-formation in which he sacrifices his reality testing sufficiently to create a rigidly held fantasy of being one with his mother, inseparable and united, with a blurred boundary between them in which he is an extension of her and she is incorporated into him. In this way he can maintain the illusion that he can both partake of and possess her awesome magical powers and have her inside of him and be inside her so that he can keep track of and control her destructive rageful aggressive capacities. There is denial and alteration of perceived reality to maintain rigid defensive fantasies. Creative capacities are subjugated to the need to create and maintain a defensive perception of himself as fused with the terrifyingly powerful, awesome mother figure which he must control. This is peremptorily played out continually or continuously. Mere fantasy is insufficient to ward off the powerful anxieties. The fantasy of union must be objectified in action. It is difficult for him to invest in his penis or to retain an Oedipal, competitive interest in his mother without intense anxiety because in his view both of his parents threaten him with castration. It is easier for him to give up his masculine strivings and Oedipal interest in his mother in favor of identification with her and her powers. Can psychoanalytic treatment help such a youngster? And what special parameters might be indicated? Not all boys who are brought for treatment for gender disturbances show such profound emotional disturbances, however. At times they appear to have gone through preoedipal conflicts that have made for intense separation anxiety and have impaired the development of a strong, independent identity, but they have gone on, nevertheless, to a predominance of intense Oedipal conflicts, with enormous fear of castration that makes it dangerous to be a boy. For these boys, there is no question of the suitability of psychoanalysis as an appropriate treatment modality.
Bobby illustrates the more profound clinical picture within this constellation. He was referred for analysis by his mother's analyst, who also sent his father into analysis. Bobby's mother had had an extremely unsatisfactory relationship with her own mother, who had left Bobby's grandfather to aggressively pursue a career at which she was highly successful. She was depicted to me as cold, nongiving, and self-centered. Bobby's mother had been in a lesbian relationship for a number of years before she gave it up following a course of intensive psychotherapy. She went on to marry Bobby's father, who had started out in a highly competitive field only to give up for a safe, noncompetitive, intellectual field that paid much less than he had been earning and that put him into a dependent relationship with the man who owned the company. Although she tended in general to be depressed, anxious, self-denigrating, and lacking in confidence, Bobby's mother was extremely happy, almost euphoric, during her pregnancy with Bobby. It was the best time of her life. She was certain from the beginning that the baby was a boy. When Bobby was born, she was enraptured. From then on he was the center of her life. She was delighted with his good looks, his intelligence, his aesthetic sensibilities (e.g., he was sensitive to colors and textures from a very early age), and his devotion to her. She did not mind that he was born with a congenital disorder that presented no problems but for which he required close medical supervision, that he was timid and clung to her, that he was extremely fearful of bodily injury and preferred the company of girls to that of boys, whose roughness and physicality made him uncomfortable, that he showed an interest in dressing up in her clothes and then in dressing up in female clothing in nursery school, and that he was madly in love with the little girl next door and annoyed her by repeatedly trying to kiss her. She did not mind, until her analyst began to express some concern, that Bobby's father threw himself into his work and spent very little time with Bobby. She was very much the dominant one in her relationship with her husband, who was shy, timid, passive, and unassertive. What precipitated Bobby's referral for treatment was his mother's and then Bobby's reaction to his brother's birth when he was four years old. His mother was pleased by the pregnancy, but remained very attached to Bobby during it. After the birth, however, just as she had done when Bobby was born, she became elatedly entranced with her new baby boy, with whom she was totally involved, with nothing left over for Bobby. She now had no interest in Bobby. He had lost her. Bobby at first was bewildered, saddened, in shock. When his mother recovered enough from her preoccupation with his baby brother to return to him, he came back to his former self, but with an intensified interest in dressing up in women's clothes at school and with the addition of expressing an interest in being a girl instead of a boy. It was at this point that his mother's analyst urged Bobby's parents to bring him to me for evaluation. For the first six months of treatment, Bobby insisted on having his mother with him during his sessions. At first, he alternated between silently making physical contact with her by flying an airplane around the room and using her head as a landing strip, having a toy soldier climb all over her body, etc., and continuing fights with her which had started in the car on the way over involving something he wanted from her which she had refused to provide for him. She found both of these activities extremely uncomfortable. Initially, she indicated that her pain was in resonance with the pain she perceived he was feeling. Then she revealed that not only was his anger at her extremely difficult to tolerate but so was his hunger for physical contact with her. They never had had a truly physical relationship, she said, despite the intensity with which she was enamored of him. Touching each other, hugging, displays of physical affection between them were appearing for the very first time during the sessions in my playroomâ€”and the sessions were "very difficult" for her.
One day, as Bobby was flying his airplanes around the room, instead of going by me he decided to land an airplane on my head. He quickly looked over to see how his mother would react. Her initial response was to chastise him, but she caught herself, took back what she had said, and indicated that she could leave it to him and me to deal with this new step. When I permitted him to use my head as a landing site, Bobby responded by including me more and more in his play, at times apparently to tease and test his mother but increasingly to expand his play world so as to include me in on it. A few weeks later, he playfully pulled my glasses off my head and put them onto his own head. His mother winced slightly but raised no objection. During the next session, Bobby put on my glasses, sat down next to me, and said "I'm little Dr. Silverman." This was a bit too much for Bobby's mother. She became "confused" about the time available for some chores and she and Bobby missed the next session. When we spoke on the telephone, she readily recognized that she had responded to Bobby's increasing closeness with me by becoming very uncomfortable. She indicated that she did not think she could continue to be present during his sessions with me much longer. Anyway, she said, Bobby seemed to be getting to the point where he would not need her to be present while he worked with me. When Bobby became able for the first time to have a session alone with me, he insisted that he felt no anxiety. Shortly after his mother left, however, he reached under the toy cabinet and pressed the button to buzz the outer door which he had discovered was under there. When I asked why he had done that he replied, "I'm pushing the panic button." Our talking together about the extreme vulnerability he felt when he was alone, without his mother, led quickly into play, which extended for months, with a character he had introduced while his mother was still present in his sessions, but until now had played only a small part in what transpired when he came to see me. This was the "evil princess," which Bobby made by wrapping the mother doll from the doll house corner with different colored papers to give her elaborate gowns. She was "beautiful" and had magical powers, chief of which were her ability to fly, her ability to make herself invisible, and her ability to heal all injuries done to her and to come back to life if she were killed. Our investigation together into Bobby's ascribing these particular powers to her and into his repeatedly dressing and redressing the evil princess, which stretched over years, shed light into many, related things. These included his feelings of utter helplessness and vulnerability, his abject terror whenever he had to go the doctor and have blood taken from him, and the panic he felt about his health. It turned out that he believed that he was in extreme danger to his life because of his congenital disorder (which actually presented no threat whatever) and because of his intense ambivalence toward both his parents and toward his little brother. These were connected further to intense castration anxiety. We discovered that Bobby lived in constant terror that his mother would abandon him, whereupon he would die. His interest in dressing up in women's clothing and his expression of the wish to be a girl became understandable in terms of his unconscious belief that it was only by being one with his mother that he could survive. Time permits no more than mention of the seemingly endless stretches of Barbie doll play, from which he eventually progressed to Teenage Mutant Ninja Turtles and other superhero play as he came to dare to aspire to masculine powers rather than the feminine ones he initially believed he needed. Also prominent were the preoedipal and Oedipal rivalry Bobby came to express, in doll play and then in dramatic play, in which the children joined with the mother in banishing, hanging, or otherwise killing the father to remove him from the scene so that they could be happily together without him. It was initially very difficult to get Bobby's father to involve himself in the analysis (or, for that matter, in Bobby's life), but shifting one of our sessions to Saturday morning so that his father could bring him helped enormously. I shall only mention the many, many baseball games we eventually played, which initially exposed Bobby's powerful fear of physical injury, but then became a vehicle for assisting Bobby to express his masculinity and his masculine rivalry without so much terror of paternal retribution
and maternal abandonment, the endless card games and chess games that succeeded the baseball games when winter approached, the work that was done involving his pregnancy envy and rage at his mother's pregnancy and at his little brother, and the work that was done to help him understand and come to terms with his congenital medical problem. The analysis was long, but not long enough. Eventually, it was brought to an end by his parents a year or two ahead of my own projected timetable, ostensibly because he had improved enormously, needed to have after school time for socialization, and because of the financial drain his analysis represented on top of his parents' own, endless analyses. Follow-ups have been provided, which indicated that Bobby was doing well, albeit still quite esthetic, relatively unassertive, very interested in colors and designs, and intermittently aggressive toward his younger brother. His parents join me in wondering what adolescence will bring. A large percentage of preschool boys with gender dysphoria grow up to be homosexual, whether or not they have received treatment for their gender disturbance. What does this mean? Does it mean that male homosexuality is innate and biological in origin? Does it mean that male homosexuality derives from the impact of powerful experiential forces that impinge upon children from very early on, in an ongoing fashion, and so inexorably that even intense early individual psychotherapy is unlikely to reverse their impact? Does it mean that homosexuality is variable in origin, with interaction of innate and experiential factors in variable proportion in different individuals? Does it mean that many treatments are not intensive enough, dynamically oriented enough, deep enough, or early enough to be effective? More and more clinicians and researchers are coming to the conclusion that boys with gender dysphoria require intensive, incisive, dynamic, individual psychotherapy combined with vigorous, effective work with their parents that focuses upon their parenting. If this is correct, then many treatments of gender-dysphoric boys have not been inadequate to the task. Even with optimal therapy, some of these children will be heterosexual as adults and some will be homosexual, depending on the net effect of all the complex biological, psychological, sociological, and experiential factors which can be expected to influence their development throughout childhood and adolescence. Gender identity, gender role, sexual orientation, and sexual partner orientation are all extremely complex matters, about which at this time we have imperfect understanding and a great deal yet to learn. Retrospective reports from adults or even from teenagers about the emergence of their sexual identity and sexual orientation tend to be unreliable, as is historical interpretation in general, but perhaps it is especially unreliable, given the intensity of the defensive distortions in self-perception and the intensity of the familial and societal attitudes that are impinging upon the individuals involved. Prospective studies offer a valuable additional source of information to complement retrospective reconstruction, but even they can be misleading, given the complexities that are involved.