Copyright 2012 Christian Association for Psychological Studies

Journal of Psychology and Christianity

ISSN 0733-4273

2012, Vol. 31, No. 3, 278-284

CASE STUDIES

Early in the heyday of DID, ego-state theorists

John and Helen Watkins were observing opposite
gender ego states and suggesting that sexual identity needed to be studied from an ego-state perspective (Watkins & Watkins, 1982). They
reported that opposite gendered ego states
seemed to be organized around the stereotypes of
maleness or femaleness. More recentiy, Howell
(2002) has speculated that much of gendered
behavior, and especially its pathological extremes,
derives from trauma and that specifically gendered 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 creating 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 pragmatically on the manifestation of same-sex behavior and
attractions in DID patients that arise from the
activity of opposite-gender identities. By reviewing the psychodynamics of this phenomena, I
think important insights can be gained for the
therapeutic care of DID patients as well as a subset of adult victims of childhood trauma who
report same-sex attractions and behavior.

Opposite-Gender Identity States in Dissociative Identity Disorder: 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 psychological condition wherein the individual experiences (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 personality states recurrently take control of the person's behavior, resulting in (3) an inability to recall
important personal information that is too extensive to be explained by ordinary forgetfulness and
is (4) not explained by substance abuse or a general medical condition (American Psychiatric Association, 1994; Intemational Society for the Study of
Trauma and Dissociation, ISSTD, 2011). Generally,
DID is considered a trauma-driven disorder, presumably originating out of recurrent abuse commencing in early childhood. While subjectively
compelling for the patient, these alternate identities are not separate persons but rather enactments
of trauma related intrapsychic conflia, 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 5066% of DID patients have at least one oppositegender identity (MacGregor, 1996; Putiiam, 1989;
Ross, 1989). Putnam indicated that child, adolescent, 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 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 discovery 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 controlled, this impulsive act so startled Gina that she
readily consented to treatment. Over the course
of several months in therapy, it became evident

Correspondence concerning this article should be

addressed to Dr. Christopher H. Rosik, Link Care Center, 1734 W. Shaw Ave., Fresno, CA 93711. E-mail:
christopherrosik@linkcare.org
278

that Gina was reporting symptoms that could be

explained by the activity of dissociated identity
states. These included experiencing internal egodystonic voices, not recognizing her face in the
mirror, not recalling some things others told her
she did, and sometimes perceiving her environment as if she was looking through the small end
of a pair of binoculars. Following a period of
psychoeducation regarding dissociative experience and the mobilization of her limited support
system, I conducted interventions aimed at contacting potential alternate identities. This confirmed 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 reporting 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 reported abuse memories in DID patients, memories of
ordinary childhood abuse among DID patients
have been highly corroborated (75-90%). Memories of ritual abuse are rarely corroborated (020%) 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 attractions in large degree because of her religious values. 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 baffled 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 relationships 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 religiously 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 challenged, 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 communication among Gina's alternate identities further
eroded the dissociative barriers and provided a
greater context for Alex to empathically understand the nature of the trauma they had experienced, 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-oriented 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 reactivation 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 dissociative coping mechanisms and having to develop more adaptive coping skills. The treatment
needs related to Alex would not be complete
without assisting Gina post-integration to develop greater skill and comfort in her social relations (particularly with men), a task which took
significant time to accomplish despite her great
desire to achieve a level of heterosexual functioning that was satisfying to her.

CASE STUDIES

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 heterosexual 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 sexuality (Putnam, 1989). The psychodynamics of these
alternate identities appears to be somewhat different for women and men DID patients, which justifies 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 alternate identities have much more to do with preserving 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 identified 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/Idendfying 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

1
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. Homosexually 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 dissociating 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 lesbianism (MacGregor, 1996; Ross, 1989). Alex
appeared to have developed this function subsequent 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 identity 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 religiously conservative patients. This dissociative
strategy solves the problem of how to have sex
with a same-sex partner while maintaining a heterosexual self-identity (Ross, 1989). A homosexual-oriented female alternate identity can also
accomplish this task.
Procuring intimacy and affection. Since the
female DID patient sexually abused by male perpetrators typically have great difficulty in their sexual relationships with men, male alternate identities
who are sexually attracted to women may also
serve as a primary means of obtaining physical intimacy, 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, homosexually-oriented female identities may be the more common means of gaining comfort.

Performing "masculine" tasks. Putnam

(1989) noted that male alternate identities in
female DID patients sometimes serve as

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 operations or sports activities.
Female identities in male patients
There is much less literature devoted to the presence 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 oppositegender identities, this statement has not been
repeated or confirmed in the subsequent literature.
Transgenderism and transsexualism
Worth mentioning in the context of oppositegender identities are their potential involvement
in certain cases of transgender and (should sexchange surgery be pursued) transsexual identities. Putnam (1989) noted that many male DID
patients present with host states that are outwardly effeminate and often homosexual in orientation. 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 dissociative in nature. He cited the example of having
assessed a man for sex-change surgery only to
discover that a female identity within the undiagnosed 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 Transgender Health's 7"' 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 explanations. However, the Standards of Care do explicitly refer to DID as one co-occurring condition for
which gender nonconforming clients should be
evaluated, particularly prior to sexual reassignment 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 evidence 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 & Mller, 2006).
Recent reports suggest that while SRS often
improves sexual functioning and gender dysphoria 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 dissociation and same-sex attraction/behavior interaction. Although the WPATH Standards of Care
(2011) explicitly mention DID as a possible cooccurring 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 Guidelines 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 familiar with these guidelines as well as the controversies involving sexual orientation change
(American Psychological Association, 2009; Jones,
Rosik, WUliams, & Byrd, 2010).
Thus, while somewhat dated, the literature germane to DID and same-sex attractions and behaviors cannot be easily dismissed. The
psychodynamics of opposite-gender identities in
DID provides clinicians with some beneficial

insights for psychotherapeutic treatment, particularly where unwanted same-sex attractions and
behavior have been reported in traumatized
patients who evidence a significant degree of dissociation. 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 backgrounds. While it may be tempting for therapists 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 therapist 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 cognitions and self-perception are addressed, the psychological 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 processing of traumatic material and correction of related cognitive distortions. Ross (1989) observed
that opposite-gender identities can be integrated
with no disturbing effect on the patient's primary gender identity.
Trust is a must
It is impossible to stress how important the
establishment of safety and trust is in the treatment of DID related unwanted same-sex attractions 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 conservative Christian patient, in particular, is quite likely to have already internalized condemnatory
messages regarding same-sex behavior, so that an
early treatment goal is to facilitate the development 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-gender identity may not even perceive the sexual
behavior in this manner and consider the therapist'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 provision 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 barriers and promoting integration of identities
begins. As dissociation gives way to re-association, 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 protective 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

alternate identities. It is evident from this analysis 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 homosexuality. 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 arriving at any peremptory determination on this subject, I want to close by making two observations
that I believe will ensure a scientifically responsible 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 examples such as that of Gina have a primarily heuristic 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 understanding 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 necessarily 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 perspective, 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 profession's ability to alleviate the suffering of some
individuals who present with histories of trauma
and unwanted same-sex attractions and behavior. 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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