Sexuality Conflicts Depression and Anxiety in Female Patients: The Neglected Path

Menopause is an object of disavowal and even fright for many psychoanalytic writers [5]. Our library search on the topic produced rather meager results, especially for recent years (1990-2007). Even the influential book “Psychoanalytic Theories of Development” by Tyson and Tyson [6] does not address menopause in its chapter on Gender Development. This scarcity is rather striking in light of the proliferation of articles and books dealing with femininity, female sexuality, and motherhood. Terms such as “sexuality” and ”desire” are seldom mentioned in relation to menopausal women despite the fact that there are, on the average, still some 25 years left to reach old age after menopause! It seems like nothing has changed since ancient cultures defined menopause in women as marking the beginning of old age. It is of interest that Freud himself related to the issue of menopause with much more optimism than what we find in his followers’ writings. In 1912, Freud [7] wrote: “Because a certain period of life is reached, along with the biological processes ruled by law, the quantity of libido in their psychical economy has undergone an increase which in itself would be enough to upset the balance of health and create the condition for neurosis. As we know, such somewhat sudden increases in libido are regularly associated with puberty and menopause, at the times when women arrive at certain ages” (p. 124). In 1913 Freud [8] stated regarding menopause that only when it is impossible for libido to find release in satisfaction or be transformed by sublimation, that the outcome might be illness of an obsessional nature. The comparison of menopause to puberty appeared again in his writings in 1926. Thus, Freud [9] believed that menopause is similar to puberty in the increase in libido it brings with it, but that frustration due to the loss of loveobjects in the external world might turn this increase into neurosis.


Introduction
Biran, Britton and Yarom [1][2][3][4] described the tendency of the girl to over-identify with her father as a compensation for an impoverished relationship with the mother of early childhood, resulting in what he referred to as the "masculine protest. " Menopause is an object of disavowal and even fright for many psychoanalytic writers [5]. Our library search on the topic produced rather meager results, especially for recent years (1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007). Even the influential book "Psychoanalytic Theories of Development" by Tyson and Tyson [6] does not address menopause in its chapter on Gender Development. This scarcity is rather striking in light of the proliferation of articles and books dealing with femininity, female sexuality, and motherhood. Terms such as "sexuality" and "desire" are seldom mentioned in relation to menopausal women despite the fact that there are, on the average, still some 25 years left to reach old age after menopause! It seems like nothing has changed since ancient cultures defined menopause in women as marking the beginning of old age. It is of interest that Freud himself related to the issue of menopause with much more optimism than what we find in his followers' writings. In 1912, Freud [7] wrote: "Because a certain period of life is reached, along with the biological processes ruled by law, the quantity of libido in their psychical economy has undergone an increase which in itself would be enough to upset the balance of health and create the condition for neurosis. As we know, such somewhat sudden increases in libido are regularly associated with puberty and menopause, at the times when women arrive at certain ages" (p. 124). In 1913 Freud [8] stated regarding menopause that only when it is impossible for libido to find release in satisfaction or be transformed by sublimation, that the outcome might be illness of an obsessional nature. The comparison of menopause to puberty appeared again in his writings in 1926. Thus, Freud [9] believed that menopause is similar to puberty in the increase in libido it brings with it, but that frustration due to the loss of loveobjects in the external world might turn this increase into neurosis.

Mia W Biran*
Miami University, Oxford, Ohio, USA problem was a crisis in a relationship with a male colleague at her work place. She expressed a sense of puzzlement about the intensity of her feelings of anxiety and depression and wished to understand the depth of her reaction. Ms. N was the first born child and had two younger brothers. She was never married and had no children. She was not aware of any major psychological problems earlier in her life, and proceeded with her professional career in a timely fashion.
In the opening phase of the treatment (6 th week) she had the following dream: "This dream reminds me that when I was 4 or 5 years old, I used to run around without a shirt on, like my brothers, and I felt so free. I also used to try urinating standing up, like my brothers. In elementary school and in high school I used to compete with the boys, both in sports and in the classes... "

Abstract
This paper reviews the neglect of sexuality conflicts and confusions in adult female patients in the psychotherapy literature and some possible causes for it. This problem was already pointed at by Biran, Britton and Yarom.
Biran described a case of 50-year old female presenting dream material, memories, and associations revolving around gender identity conflicts (see below). In another paper, Biran presented a case of a menopausal patient with depression related to the reemergence of old sexual identity conflicts. Yarom perceives hysteria as a problem resulting from thwarted sexual development. For both the boy and the girl, the development of sexual identity is halted due to pathological reactions from both parents. The resulting hysteria expresses itself through 1) Vacillations in gender identity (Am I a man or a woman? Am I weak or strong, passive or active?); 2) Over usage of repression, dissociation, splitting, denial and foreclosure; 3) The use of the body and mechanisms of conversion to represent and project the internal conflicts around sexual identity. All of these defenses are operating in the transference and countertransference between therapist and patient.
"This might sound odd, but as a young child I developed a feeling that my pubic bone was protruding. Perhaps that's why I tried urinating standing up. I still feel this way, even though I know this is not rational, but I still have this odd sensation. " "My mother did not encourage me to be feminine. She dressed me and my brothers in the same clothes, and gave us baths together. Until our teen years we also slept together in the same room. " Her termination date was discussed some 6 years later and within two weeks she brought the following dream:

"I am with my boyfriend (a relationship of a year-long, which is described in positive terms) in bed. It is a very warm night and I am fully naked. I feel happy and comfortable. Suddenly, my boyfriend turns into my mother. At first I am really startled, but soon I calm down, she is smiling at me, and I feel happy again. My boyfriend wakes up and touches my breast gently. He is very tender and loving. We make love. "
Her associations to the dream: "In taking care of my mother when I visit home (mother has developed Alzheimer lately) I discover my ability to nurture and love. I want to give her so much. I wish I had a child; I could be a good mother. I like helping her with basic bodily functions. I can hug and kiss her now, something that I was so reluctant to do in the past. " "I gain my place in the family now by finally being the daughter, rather than the a-sexual, non-identified person I think I may want to move in with my boyfriend. " "I feel as an adult for the first time in my life. I am taking a course in swimming and I feel comfortable with the women in the class. " "Something about my relationship with X still feels very adolescent. We should move in with each other. I start to accept my femininity. I have a lot to give. I have changed a lot. I used to be afraid of rejection, did not have a sense of a self. It is really interesting that exactly now, when I go through menopause, I feel more feminine. "

Discussion
The patient arrived to therapy complaining about high anxiety and depression that were triggered by a power struggle with a man at her work place. As we look at her first dream in therapy and her associations we can clearly deduct that her issues originated in her conflicts about her femininity and sexual identity that started at the early age of 4-5. At that point in her development she rejected her female body and wished to be a male, like her brother and what she perceived her mother preferred. One confronted with the struggle with the man at work, this early conflict surfaced with full steam and she had no way of understanding her emotions.
After some time in treatment she was able to recognized those early conflicts, work them out, and strengthen her perception of herself as a woman with a body of a woman, as can be seen from her second dream and associations to it. Concomitantly, her anxiety and depression subsided and she found herself enjoying her work and love life.
As we remember, Freud taught us the sexual difficulties are the cause of mental disturbances. Nevertheless, we observe a decline in the status of sexuality, especially with regards to female patients, in recent literature. There are several lines of explanations for this decline: 1) The rise in the popularity of contemporary psychodynamic theories, such as Relational, Intersubjective, Object Relations, Selfpsychology and Attachment.
2) The fact that more therapists experience uncomfortable reactions to dealing with raw sexual material, and prefer to label it as "out of control" behavior rather than analyzing it.
3) The increase in concern about legal actions based on sexual boundary violations which might deter therapists from dealing with "hot" material. 4) Male therapists are often oblivious or uneducated in female developmental stages and the specific sexual issues at different stages of female life (e.g., menopause).