A fe/male transsexual patient in psychoanalysis

The author describes the analysis of a transsexual who had undergone a vaginoplasty as a young man and had since been living as a woman. The complexity of the psychic reality is epitomised by the analyst's difficulty in deciding whether to use masculine or feminine grammatical forms to refer to this patient. The author tells how she assumed the fantasy role of parents expecting a baby whose sex they did not yet know. She discusses at length her hesitation about accepting a transsexual patient into analysis and reports how she overcame her misgivings after analysing her own countertransference and consulting the literature. Noting that this borderline analysand resorted to both psychotic and neurotic mechanisms, the analyst decided to rely on the capacity for symbolisation and mental representation evinced in the latter. On the psychotic level, the delusional neo-reality of the appearance of a woman sought to replace the unbearable reality of being a man, whereas the neurotic part was aware that s/he could never really be a woman. The author observes that in this analysand sexualisation served to conceal a fundamental narcissistic fault. She also describes how she worked with her own madness to help the patient emerge from a situation of paradoxical fusion with the mother in madness.