This chapter examines how early relationships become established relationships. It reviews varying relationship trajectories (e.g., ascent, peak, and descent) and then describes the three key components of the relationship that develop over time: love, intimacy, and commitment. First, the chapter defines and differentiates the various forms of love (e.g., passionate love, companionate love, compassionate love) and reviews how love develops and changes over time. Second, this chapter explores how interpersonal intimacy develops through repeated instances of self-disclosure and perceived partner responsiveness and how developing intimate relationships change the self. Third, this chapter reviews how people make and communicate their commitment decisions, as well as how social network members shape commitment. Finally, it provides an overview of common major transitions (cohabitation, marriage, parenthood) and some key challenges therein.

Coping refers to the multitude of actions individuals use to manage stressful encounters. In this chapter, we first describe stressful peer events during childhood and adolescence (e.g., bullying, rejection, victimization), focusing on their impact on mental health but also how they can provide opportunities to apply coping skills. Second, we address how peer relationships, at the group and the dyadic level, are prime settings for the development of coping by considering 1) the soothing and distracting presence of peers, 2) the selection of peers, and 3) the socialization of emotion and coping that can occur within peer interactions and relationships via processes of support, communication, and disclosure. We end with brief notes on the important consideration of the quality of peer relationships and the usefulness of considering gender (and cultural) differences, especially focusing on moderation effects to uncover whether these processes differ across gender and cultural subgroups.

This chapter is a fictional account of several people talking about aspects of their lives that are impacted by variations in sex development at a support group meeting. In their exchanges about past, present and future medical encounters, the author draws out both the opportunities and the dilemmas presented by medicine. Through the characterizations, the author also teases out some of the most pertinent psychological themes in the field, such as how to decide about “normalizing” surgery for a child and how to talk about bodily differences in relationships. These themes are centralized in Chapters 9–14 and explored in the literature summaries and practice vignettes therein.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Counseling patients through their journey to conceive can be challenging. When a therapist becomes pregnant, the therapeutic alliance alters.This chapter explores the unique dynamics between the pregnant fertility counselor and reproductive clients. Questions around the “who, what, where, when, why and how” of pregnancy disclosure are used as a tool to help think about the various elements to the therapeutic alliance. Intense feelings can be triggered for a patient who is struggling with infertility or pregnancy loss, but can also trigger emotional reactions for the fertility counselor. The transference and countertransference that arises with the self-disclosure of a pregnancy is likely to unfold complicated dynamics and emotions. The positive and negative implications that a pregnancy disclosure can have from the patient’s point of view, as well as that of the therapist, are addressed. Additionally, the postpartum experience and the return back to work after parental leave are also discussed. While this chapter focuses on the pregnant therapist, the issues raised pertain to all pregnant reproductive medical staff treating infertility patients.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.

Chapter 9 tackles the theme of choosing “normalizing” interventions, which applies to children and adults with variations. It explores the limits of choice regarding invasive and irrevocable “normalizing” interventions in the field of sex development. It considers the role of emotion in decision-making and the complexities of obtaining informed consent. In the practice vignette, demand for surgery by a young person (with CAH) is a foregone conclusion – a familiar scenario in DSD services and one that places the psychological care provider (PCP) in an ambiguous position. The service user also has clear psychosocial care needs. She brings a unique suite of intersecting social circumstances that place demand on the PCP to be fluid and responsive to the dynamic and challenging referral context. The PCP in the vignette does not have the answers, but it is hoped that the story opens up conversations on the theme.

Psychological care is endorsed in DSD medicine. Psychosocial research has been on the increase. But these positive moves have not given psychological practice the kind of collective focus that is enjoyed by the biomedical disciplines. However, psychological care providers have a wide variety of thinking tools and practice techniques to draw on, if to work in an ad hoc way at times. These tools and techniques do not change, but some are more useful and relevant than others for this service context. In Chapter 7, the author discusses the strengths and weaknesses of key theoretical frameworks in healthcare psychology. A major weakness of the individualistic models is their lack of capacity to address structural inequalities in psychological wellness and distress. The author introduces aspects of the Power Threat Meaning Framework and describes how to draw from its theoretical richness to think systemically about what sex variations pose to individuals and families in the social context and how they are responded to. The Framework provides the theoretical backbone for some of the practice vignettes in the final section of the book (Chapters 9–14).

In the 1990s, some former patients mounted street protests in front of medical conferences to draw attention to their trauma. They reclaimed intersex as a personal identity and campaigned for healthcare reform. These developments are the focus of Chapter 5. Intersex is coming out of the closet more and more, through being a topic in television documentaries, novels, films and art. Intersex activists challenge medical authority to change practice. Furthermore, they are not waiting for doctors and scientists to come to their viewpoints. They have successfully lobbied human rights agencies to position childhood genital surgery as a violation of their human rights. They demand that surgery is delayed until the child can give informed consent or is at least old enough to participate in the discussion and offer their agreement.