This qualitative study examines the relationship between gender and narcissism through interviews with psychoanalysts about their work with men and women with narcissistic pathology. The study found that there were conflicted, ambivalent experiences of gender in many patients with narcissistic disorders. There are two significant expressions of this gendered ambivalence: struggles in the physical body and interpersonal struggles based in an ideal version of what it means to be male or female. The first involves a physical sense of oneself as not fully male or female. The men in this group have a preponderance of feminine identifications along with masculine identifications and experience gender confusion. Their conflict about their masculinity is frequently expressed in feelings in and about their bodies. The women in this first set tend to have deficient female identifications that manifest themselves in the experience of their bodies as faulty or damaged. The second expression of gender ambivalence tends to manifest itself in relation to others, including the analyst, and involves an idealized version of masculinity and/or femininity. In both groups the struggles include gendered issues of subjectivity, power, aggression, dependency and creativity. Early family dynamics appear to play a role in the development and expression of gendered conflict in men and women with narcissistic pathology. For those narcissistic patients with embodiment issues there tends to be an intrusive parent. For those with an interpersonal expression parents tend to be hyper-critical or neglectful. Struggles in the realm of gender play out in the treatment and are important in understanding the transference and countertransference dynamics.