Gender
NINE OUT OF TEN patients who have been diagnosed with multiple personality disorder are women. The same proportion is observed in old cases of double consciousness or alternating personality. I do not claim the latter as a statistical fact, because it depends whom you count. One survey finds a larger proportion of males among old reports than I do.1 But whatever proportion one fixes on, the majority of multiples are female. Why?
There is another question about gender and multiple personality. Multiples now develop a large number of alter personalities or personality fragments, some of whom are of the opposite sex, or promiscuous, or bisexual, or homosexual, or some combination of these gendered traits not found in the host personality. Are these instabilities in sexuality a superficial phenomenon, or is sexual ambivalence integral to the disorder and its causes?
Nine out of ten diagnosed multiples are female. That sounds as if there were some well-established piece of knowledge, a Fact of Epidemiology. There is no such thing; there are only a few data and a good deal of anecdotal experience. We have a consistent impression that the vast majority of patients have been women.2 This may result from a mix of only loosely connected causes. For example, throughout most of the nineteenth century and even into our own, multiples were also said to have hysterical symptoms. In the great French wave of multiples, all multiples were, first and foremost, florid hysterics. Whatever else may be true of hysteria, it is a thoroughly gender-laden diagnosis, description, or discourse. Questions about multiplicity yield to the overarching question about the gender role of hysteria in French clinical practice. I shall touch on some of those questions later, but for the present we should examine only recent information.
In 1986 Frank Putnam and his colleagues published the results of their now-famous survey. Questionnaires were sent to clinicians, and, as I understand it, the sample was constituted by the first 100 patients recorded in replies that fit the protocols of the survey; 92 of the 100 patients reported were women.3 Three years later Colin Ross and his associates published a larger series, again based on a mailed questionnaire. It was sent to two populations of clinicians, members of the ISSMP&D, and Canadian psychiatrists selected by Ross. Of 236 cases reported, 207—that is, just shy of 90 percent—were women.4
Why the imbalance? The earliest and still the most common explanation may show more about attitudes to gender than about multiplicity. There are, it is suggested, a great number of male multiples out there but we are not diagnosing them. It is as if the fact that most of the people who suffer from a certain mental illness are women produces a feeling of guilt, of political incorrectness even. Perhaps this is partly because a female complaint has less cachet than a male one—just another instance of the powerlessness of women. At any rate, the drive to find more male multiples has been a constant theme from 1970 to the present day. When gender is discussed, the most common question asked is “Where are the men?” Contrast people with other problems. Most alcoholics are men. We do not hear ringing cries of “Where are the female alcoholics?” A few epidemiologists do ask why schizophrenia is more common among men than women, but no one imagines that we have to search through new populations in order to find more female schizophrenics.
Where are the male multiples? Cornelia Wilbur proposed that they are to be found in the criminal justice system rather than the mental health system.5 Hence the aphorism “Most males with MPD are in jail.” There is a slightly less loaded way to understand the suggestion. Perhaps these gigantic unsystematic “systems” of health and justice play an important part in channeling and organizing symptoms and their display. Not only do people of different sex get caught by different systems, but also the functionaries and people with little pieces of authority within these systems work on those whom they catch in order to train them to fit in with expectations. And of course once you are caught by justice or mental health, the easiest thing to do is to behave as you are supposed to—violently or weakly, as the case may be. It becomes second nature. That is a traditional suggestion of labeling theory: people adapt their natures to the labels assigned to them by authority.
Wilbur suspected from early on that there was a missing mass of male multiples. She may have felt vindicated when she worked as a consultant in the case of Billy Milligan, the Columbia rapist who pleaded that his crimes had been committed by alters. In contrast, Ralph Allison did at first believe that male multiples had to be rare, because so few men suffered as much extreme youthful trauma as his female patients. But then he realized that the “trigger” need not be sexual abuse but only “trauma so severe that the child had to flee inside his head, creating a new personality to take his place.”6 Moreover, violent behavior, albeit the work of vicious alters, was all too socially permissible. That was why so few male multiples showed up for help. One of his most important patients, Henry Hawksworth, was a gentle man who would get drunk and have fabulous barroom fights of which Henry had no memory. A judge thought the fighting exploits were so stupendous that he let Hawksworth off with a caution and told him not to drink so much and to quit watching cowboy shows on television. Yet in Allison’s therapy, it was one of Henry’s alters who decided to get drunk, or, when drunk, got into brawls. On the other hand, when the behavior went over the edge, it really went over the edge. I have already described Allison’s patient who in an alter state set fires and later raped and murdered a woman.
The deep-felt need on the part of some clinicians to find more multiple males virtually guarantees that in the short run an increasing proportion of males will be diagnosed with dissociative identity disorder. Ross thinks that “the clinical ratio will probably drop over the next decade as MPD is diagnosed in prisons and other settings.” He argues that hypnotizability is strongly correlated with multiple personality disorder, and asserts: “Given that men and women are equally hypnotizable and do not appear to differ in dissociative experiences in the general population, the sex ratio of MPD ought to be about the same as the ratio for abuse (somewhere between 1:1 and 9:1).”7 There is something chilling about Ross’s deterministic prediction that once we have got the latent multiple males to behave properly, that is, as overt multiples, the sex ratio of multiples will be identical to that of children who are both abused and hypnotizable.
The male multiples will come from a variety of sources. The quest has already prompted a research interest in prison populations. There is also the class of patients treated in the U.S. Veterans Administration hospitals. Post-traumatic stress disorder has become a common diagnosis. Clinicians who treat it are increasingly open to a diagnosis of multiple personality. In another direction, the interest in child and adolescent multiples may produce numerous males because disturbed boys are more of a nuisance than their female counterparts and come more readily to the attention of psychiatrists.8
The factor of males abused in childhood by their mothers may also become increasingly pertinent as this concept is applied to the treatment of men in unsatisfactory marriages who are given to drink and womanizing.9 A recent study reports twenty-two men who have never been arrested or behaved in a way to warrant felonious arrest. These cases confirm the pattern that male multiples do not seek psychiatric help except in connection with other difficulties such as alcohol, temper, or marital discord.10
Although the net for men has been cast wide, and although its mesh is tight, crime and violence continue to provide the majority of public accounts of male multiples. We must not discount the interaction between fact and fiction here. At first glance, fact and fiction are completely mismatched. The fictional multiples are men, the diagnosed real ones women.11 But when we look again, the match is perfect, because the stories are almost all stories of violence or crime. Among the greatest tales, only Mr. Golyadkin in Dostoyevsky’s terrifying The Double is wily rather than violent; the terror results from ambiguity rather than sadism. The prototype of the double in romantic fiction was furnished by E.T.W. Hoffmann, James Hogg, and Robert Louis Stevenson, all of whom wrote about men, but all of whom were also well acquainted with the relevant medical literature and with experts who knew that women, not men, were the doubles.12
Only one great female double was imagined during the nineteenth century, and she was an Amazon. Heinrich von Kleist’s Penthesilea of 1808 is a searing play in which the heroine acts almost exactly according to the prototype of doubling then current. In one state she is “sweet as a nightingale”; in the other she is so ferocious that she horrifies her closest companions. She passes between states by an intervening trance. She has two-way amnesia between alters, except for a slight, dreamlike recollection, in her gentle state, of what happened in her fierce state. Finally, in her fierce state she not only kills Achilles—a man whom she loves and who loves her—but attacks him with mastiffs after she has driven an arrow through his neck. Then she leaps off her horse and, on her knees in the company of her dogs, helps tear Achilles limb from limb and devours his flesh. Before she kills herself, in her gentle state, she kisses the remains.
A kiss, a bite—how cheek by jowl
They are, and when you love straight from the heart
The greedy mouth so easily mistakes
One for the other.13
After that, every subsequent story about a double seems tepid. Nevertheless, she is the only woman on the roster; all the rest of the better-known gothic tales of doubling are about men.
I regularly turn, in this book, from the clinic to works of the imagination, because clinician and storyteller so obviously reinforce each other. The earnest search for male multiples follows the trail laid by the novelist. It also distracts from more pressing questions of gender. Why is it that women come to be diagnosed as multiples far more often than men? Four explanations have been canvassed, all heavily influenced by background opinions about multiple personality. They are by no means mutually exclusive.
First, there is the crime hypothesis I have been discussing. Men with latent multiple personalities are violent and fall into the hands of police rather than doctors. Moreover, the anger of female multiples tends to be self-directed, with self-mutilation being quite common.
Second, it is suggested that multiples make an implicit choice that fits in with their cultural milieu. At any time, people suffering severe psychological distress that is not of organic or other biological origin “choose” from socially available and clinically reinforced modes. Dissociative behavior is a language of distress preferred by women. It may even be a means of escape; some alters may express socially inadmissible aspects of personality that the woman wants to own but is not allowed to. Thus in the nineteenth century, some women may have found in their alter a way to be uninhibited; in the twentieth century, some women may have found ways to be lesbian.14 Men choose other ways of expressing distress, such as alcohol or violence.
Third is the causal explanation. Multiplicity is strongly associated with early and repeated child abuse, especially sexual abuse. Far more girls are thought to be subject to this sort of abuse than boys. A feminist tradition in the past has expected this ratio to be about 9:1. These considerations provide a standard explanation of the 9:1 sex ratio among diagnosed multiples.
Fourth, the element of suggestion is emphasized. Troubled North American women in a therapeutic or clinical setting, even one that rigorously tries to avoid a stereotypical power structure, may cooperate more readily with therapeutic expectations than do men experiencing comparable distress. The men aggressively refuse to cooperate, and hence resist suggestion, while women, who are the cooperators in our society, accept it.
All four of these proposed explanations of the disproportion of female multiples may be correct and may work together. There is remarkably little serious discussion of the gender question in multiplicity. The very first workshop on gender held at an ISSMP&D conference took place in 1992.15 Numerous participants reported having seen more than one male multiple in therapy. One of the three facilitators, Richard Loewenstein, emphasized that at present “there are no data,” but there is little doubt about what data are expected to be forthcoming: more men. Unfortunately, the workshop quickly turned from questions about the gender of patients to questions about sexual relations between clinician and patient, a topic that seemed to fascinate many a participant.
If ever there was a field that needed some caustic feminist analysis, it is multiple personality. The most immediate feminist reaction to multiple personality, before any analysis, has rightly emphasized child abuse. But that is only the beginning of the story. Although child abuse, and the suffering of individual patients, must be resolved immediately, and in personal terms, there are larger issues in the background. Child abuse is not an isolated aspect of present North American society that can be removed by economic and psychological palliatives, preventives, and controls. Just as multiple personality is one indicator of child abuse, so child abuse is just one expression of the violence inherent in our existing patriarchal power structure. That has been a theme in powerful writings ever since the child abuse movement got under way.16 We now self-righteously condemn the sexually abusive male. Feminist critics find a lot of hypocrisy in this stance. It allows us to conceal from ourselves that the man’s behavior is only an extreme form of a more commonplace aggression toward women and children that is condoned and even encouraged, both in popular media and within the economic power structure.
The most detailed analysis of this sort specifically worked out in the context of multiple personality is by Margo Rivera.17 She is a clinical psychologist, a feminist theoretician, and extremely active in seeking public support for patients with abusive backgrounds. She does take trauma and violence against women as a basis from which to start but may regard multiplicity more metaphorically than do most other clinicians. Traumas, she writes, “are sequestered in disaggregate self-states called alters.”18 What is important for her is what people say about themselves. If they come to talk in multiple language, and in the personae of alters, then that is their way of expressing their problems. She regards detailed recollections of abuse as problematic. One aim of her therapy is “the strategic reworking of the history of experiences of trauma” leading to nondissociative coping skills.
She also encourages some patients, those who are healthy enough, to gain a larger and more political awareness of their plight. Hence she can address, in therapy, issues that many others ignore. Why are these your alters? Why are so many of them big men, or little children? Who in the real world do you think your alters resemble? Are the forms of your dissociation both personal and a reaction to the society that you find around you?
Rivera has an approach based on a well-developed political sensibility. She is deeply involved in the women’s movement but steers clear of what might be called scapegoat feminism—a feminism that, though often presented as the exact opposite of traditional religious principles and practices, in fact mirrors them closely. Recollection of trauma inflicted by father or another patriarch is very much like a Protestant conversion experience. It begins with the watchword “denial”: Peter-like, one thrice denies past abuse. Then comes therapy as conversion, confession, and the restructuring of remembrances of one’s past. But informing this familiar pattern there is an almighty twist. Accusation. Your confession is not to your sins, but to your father’s sins. We do not have Christ the Son taking on the sins of the world. The father takes on the sins that have destroyed your life, for he committed those very sins. We are not concerned with Jesus, the Sacrificial Lamb, but with an old goat, a literal scapegoat, the father, the Sacrificial Ram. This is an incredibly powerful mystique, for it draws on millennia of accumulated meanings. One of the great values of Rivera’s analysis is that it does not find scapegoats but proceeds by social critique.
Emphasis on abuse is usually presented as empowering, but it may be the very opposite. This is suggested by Ruth Leys, a rare feminist scholar who addresses multiple personality head on. She criticizes the majority feminist perspective represented by Judith Herman’s Trauma and Recovery and, in more general terms, by Catharine MacKinnon.19 Women, in the majority view, are abused. Children are abused. Females are far more frequently abused than are men. Repeated early abuse is the primary occasioning cause of MPD. Hence far more women than men are multiples. Leys speaks for a minority feminist view, which draws on the analyses of Jacqueline Rose. She urges a rethinking of the role and meaning of violence. She writes that Rose poses a challenge to “Catharine MacKinnon, Jeffrey Masson and others who, rejecting the notion of unconscious conflict, embrace instead a rigid dichotomy between the internal and the external such that violence is imagined as coming to the subject entirely from the outside—a point of view that inevitably reinforces a politically retrograde stereotype of the female as a purely passive victim.” She holds that discourse like MacKinnon’s “in effect denies the female subject of all possibility of agency.”20
Leys’s intentions have nothing in common with the merely skeptical opinion that multiplicity is the consequence of the power of suggestion on women. She implies instead that the great preponderance of female multiples is due to a covert alliance between clinicians and the patients. The alliance is intended to be supportive of women, but in fact it continues the old system of disempowerment. Leys offers a genuinely radical critique of current theories and practices connected with multiple personality. It does not dispute the prevalence of family violence or question its societal foundations. It does not deny that past abuse can, in a cultural and clinical milieu, lead to symptomatology of a florid sort. It does question the complacency of a theory that purports to take the part of the patient. It conjectures that the theory, practice, and underlying assumptions reinforce the patient’s self-image as a passive victim. Taken to one possible conclusion, this type of analysis might suggest that current theories of abuse, trauma, and dissociation are part of another cycle of oppression of women, all the more dangerous because the theorists and clinicians represent themselves as being so entirely on the side of the “victim”—whom they thereby construct as helpless, rather than as an autonomous human being.
These reflections lead on to yet another question about gender and multiple personality, one that is specifically about the illness itself. There are three constant features of the phenomenology of multiple personality, from the end of the eighteenth century to the present. One is that most diagnosed patients are women. The second is that it is very common for one alter to be younger than the host, often a child. The third is ambivalence about sexuality. Why is that so common among prototypical multiples?
Virtually every female patient, of whom there is much reporting, is said to have a second personality that is more lively than the personality regarded as the host. Words used are “vivacious,” “mischievous,” “naughty,” and, as reporting becomes less inhibited, “promiscuous.” As early as the 1820s a Scottish woman servant had sex with a man who had “taken advantage” of her second state.21 Félida X., the most famous French multiple, topic of chapter 11, conceived and gave birth in her second state, while denying pregnancy in her first state. Variations on this sequence of events are well known.22 According to Leys, there is ample evidence that the main alter of Prince’s 1906 Miss Beauchamp behaved in a way that would now be described as bisexual. Indeed Saul Rosenzweig suggested not only that Miss Beauchamp was bisexual, but that Breuer’s Anna O., described by many as being a multiple, was similar to Prince’s patient in many respects, including bisexuality.23 Gender ambivalence continued in the occasional cases reported later in the century.24 Nevertheless, there is much truth in the following statement about Wilbur’s patient Sybil: “The uniqueness which, before, was based on Sybil’s having developed more alternating selves than had any other known multiple personality, was now founded as well on her being the only multiple personality to have crossed the borders of sexual difference to develop personalities of the opposite sex.”25
After Sybil the floodgates were opened for transsexual alters. There is a close correlation between the emergence of theoretical perspectives and the emergence of different types of cross-sex alters. Thus in the late 1970s “imaginary playmates” were widely canvassed as an origin of multiplicity—many children have imaginary playmates, and it was thought that in some, the imagined figure coalesces and develops into a personality that uses the body of the host. One such male alter of a female patient was described in 1980.26 A second source of the male alters was explained as male self-fantasies of the growing female child herself—Sybil’s two male alters were prepubertal boy-Sybils who never quite grew up. Also around 1980 there was a notable stylization of the range of alters, such that one would find one or more persecutor alters, and one or more protector alters. Females developed male protector alters who were strong, heavyset, reliable—cowboys or truckers, for example. Throughout this period, the sexuality of cross-sex alters was not discussed in published reports.
As the number of reported alters increased from a typical three or four to an average of sixteen or more, the number of cases with disclosed opposite sex alters radically increased. So did the number of alters who contrasted with the host in other ways. The alters were often stereotypes of the worst sort: racial, ethnic, even stereotypes of old age.27 Notice that if a patient is to have a large number of alters, there is some difficulty in recognizing who is who. Differences that in our society are taken to be definite, immutable, and central to identity help to shore up the distinctions between multiples. In American culture the cardinal differences between people are gender, age, race, and, to a much lesser degree, income, job, ethnicity, language, or dialect. It is not surprising that when a host of type X (middle-class white American woman aged thirty-nine, say) develops distinct alters, many should be distinctly non-X, that is, of different gender, race, age, social status, or dialect.
The results of Ross’s questionnaire, based on 236 cases, showed that 62 percent of reported cases had alters of the opposite sex. But the survey only began to look into switches in gendered attributes. The combinations and permutations of gender identity have become enormous in scope. The nineteenth-century contrast, inhibited/vivacious, remains a commonplace. But now the menu of contrasts has been greatly expanded. Each alter can now be characterized by choices made from each of the following options: same sex/opposite sex, heterosexual/bisexual/homosexual, infantile/prepubertal/adolescent/mature/senile. Mixing and matching these could give sixty alter states distinguished on gender grounds alone.
That may prompt a cynical functionalist insight into the variety of gender roles: it helps to keep the alters distinct. There are, however, many deeper functions to be served by alters of different sexes. One is that, given the standard sex roles, male alters can be a way for an oppressed woman to assume power. Where in the nineteenth century the alter was naughty, mischievous, or promiscuous, in the late twentieth century she can be a man. Margo Rivera has observed:
In my experience of working with women who experience multiple personalities, it is very common for their vulnerable child personalities and their seductive and/or compliant personalities to be female and their aggressive protector personalities to be male, and other therapists with a wider range of experience than I have confirmed my clinical impression (Kluft, 1987, personal communication), though there has not been any research done so far that would document it. The experience of these alter personalities as they fight with each other for status, power and influence over the individual is powerfully illustrative of the social construction of masculinity and femininity in our society.28
This subtle analysis is combined with another one, namely, of the woman who is socially constrained to be heterosexual, but who finds in some of her alters ways of evading this social demand.29 There is a striking resonance in this insight with a very different attitude to multiple personality. Michael Kenny’s The Passion of Ansel Bourne argued that nineteenth-century female American multiples used their multiplicity to escape the confines of Protestant duty and submission. Kenny is a debunker, unsympathetic to radical feminisms, and is comfortable with those who say that therapists induce false memories. Yet there is, in both his very negative attitude to multiple personality and Rivera’s very positive one, a recognition that multiple personality is one possible response to the roles assigned to women. One way to stop being a sex object is to adopt an alternative gender role.
This idea can be further enriched. One may break out of compulsory gendering, and in particular compulsory heterosexism, by adopting other roles. Initially multiples in therapy are ill; they do not choose roles self-consciously. But suppose they acquire sufficient maturity to see that they have options open to them, and aim not so much at integration as at finding the kind of person they want to be. Then a formerly pathological gender could become the chosen way to be a person. This must be treated as a sophisticated idea. We should not think that the patient discovers some “true” underlying self but that she has broken through to the freedom to choose, create, and construct her own identity. Rather than being a pawn in a deterministic game, she has become an autonomous person. That would be the precise opposite of what, in my concluding chapter, I call false consciousness.
It would be a counsel of perfection to hope that therapy could usually have such results. It is plain, however, that multiple personality needs more gender inquiry beyond Ross’s deterministic claim, which amounts to this: the more girls outnumber boys as victims of abuse, the more women will outnumber men as multiples. Ross calls Rivera’s analysis “the feminist analysis,” instead of calling it one of many feminist analyses of multiple personality. After two paragraphs favoring a political approach to multiple personality, he abruptly switches and states that Rivera’s work “is based on linear or nonsystemic thinking,” and that it “founders” on the facts that he and his colleagues have discovered about similarities between male and female dissociative experiences.30 I have no idea what nonsystemic thinking is, but if Rivera provides an example of it, it is more valuable than simplistic deterministic thinking.
We do badly need further feminist analysis of multiple personality disorder. It need not necessarily go the way of the multiple movement. I discussed novels earlier in this chapter and will end by quoting an old-time feminist freedom fighter, Doris Lessing. I can think of very few authors less given to cant. Faye is a relatively minor character in an unnerving book published in 1985, The Good Terrorist. Faye, a revolutionary, does her best to stay clear of mental health authorities. She is English, in the early 1980s: hence there is no way, in real life, that she could have been diagnosed as a multiple by the British psychiatric establishment. But Lessing presents her very clearly as multiple, kindly sparing us the jargon. A few deft phrases and brief episodes do the work. Faye is lesbian, usually coy and Cockney, with hair in ringlets, the seductive and gentle member of a couple. But she can switch to being harsh, cruel, scary, with an upper-class accent. “Her face seemed to crumple up out of itself, suggesting some other Faye, a pale, awful, violent Faye, the unwilling prisoner of the pretty Cockney.”31 On the next page Lessing writes of “this outburst from Faye’s other self. Or selves?” In a later episode, a pathetic mother and infant are at the door of the house occupied by squatters. Alice, the novel’s protagonist,
turned to see Faye standing on the landing, looking down. There was something about her that held Alice’s attention, some deadliness of purpose, or mood. The pretty, wispy, frail creature, Faye, had again disappeared; in her place was a white faced malevolent woman, with punishing cold eyes, who came in a swift rush down the stairs.32
Faye has attempted suicide before the novel begins, cuts her wrists in the middle of it, and apparently chooses to have herself blown up at the end. In case we have any doubts about her being a multiple, her lover, Roberta, says to Alice “in a low, quick vibrant voice, ‘If you knew about her childhood, if you knew what had happened to her …’”
“I don’t care about her fucking childhood,” remarked Alice.
“No, I’ve got to tell you, for her sake, for Faye’s. She was a battered baby, you see …”
“I don’t care,” Alice shouted suddenly, “you don’t understand. I’ve had all the bloody unhappy childhoods I am going to listen to. People go on and on…. As far as I am concerned, unhappy childhoods are the great con, the great alibi.”
Shocked, Roberta said, “A battered baby—and battered babies grow up to become adults.” She was back in her place, sitting, leaning forward, her eyes on Alice’s determined to make Alice respond.
“I know one thing,” Alice said. “Communes. Squats. If you don’t take care, that’s what they become—people sitting around discussing their shitty childhoods. Never again. We’re not here for that. Or is that what you want? A sort of permanent encounter group. Everything turns into that, if you let it.”33
Lessing’s character Alice is not just saying that unhappy childhoods are the great con. She is implying that specialist knowledge of memory, sciences of memory that tell us what our souls are really like, are a great con. Lessing, in other work, has taught us about the power of memory, but she has never resorted to esoteric expertise about its nature in order to use memory as a powerful means of rebellion or liberation.