Psychoanalytic Psychology

© 2020 American Psychological Association 2021, Vol. 38, No. 4, 239– 253
ISSN: 0736-9735 http://dx.doi.org/10.1037/pap0000330

Paola on the Couch: The Quest for Feminine Identity in an Empirically

Supported Psychoanalytic Psychotherapy of a Trans Woman
Guido Giovanardi, PhD, Emanuela Mundo, MD, and Vittorio Lingiardi, MD
Sapienza University of Rome

Psychoanalytic accounts of gender variant patients in the literature are rare. Psychoanalysis with these
patients suffers from historical biases that determine short-sighted and pathologizing interpretations of
gender diversity. This contribution provides an account of a long-term psychoanalytic psychotherapy
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

taking an open and affirmative approach to gender reassignment. The patient was a trans adult woman,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Paola, during the crucial years preceding her decision to undergo gender reassignment surgery. Through
the analysis of the patient’s identifications and dreams, the psychoanalytic report focuses on the
developmental process of her transition path. The study illustrates Paola’s psychological functioning and
the therapeutic relationship, drawing on both clinical descriptions and empirical measures of Paola’s
personality and transferential and countertransferential patterns in the therapeutic relationship at different
stages of treatment. The results show the benefits and complexities of psychoanalytic treatment with
gender variant patients, during key stages of their transition journey.

Keywords: case study, personality assessment, psychoanalytic process, countertransference assessment,

gender dysphoria

Psychoanalysis of trans1 patients has a complicated and contro-
versial history. The very notion of gender identity challenges
several cornerstones of psychoanalytic theory. Sigmund Freud
(1905/1953, 1931/1953) tied the development of masculinity and
femininity to the notion of drive (Trieb), taking distance from the
biological concept of Instinkt and thus reconceiving sexual cate-
gories as not biologically preprogrammed, but psychologically
constructed (Cavanagh, 2017). However, Freud’s concept of “cas-
tration anxiety” (Freud, 1923/1953), which described both boys’
and girls’ predisposition to suffering from a “rejection of feminin-
ity” (Freud, 1953), linked sexual identity to anatomy, which,
paraphrasing Napoleon, he claimed “is destiny” (Freud, 1953).
This reductionist view—Freud himself admitted to an incomplete
understanding of women’s psychology (Freud, 1931/1953)—was
effectively challenged by authors such as Melanie Klein (1928);
Karen Horney (1924, 1926); Clara Thompson (1953), and Robert
Stoller (1968, 1976), whose seminal works contributed deep elab-
orations on feminine psychology to psychoanalytic theory, con-
trasting Freud’s phallocentric paradigm and general Victorian
thinking. In the 1980s and 1990s, the works of several authors—
mainly with a relational psychoanalytic background— began to
explore the intersection of psychoanalytic practice, academic re-
search, and feminist theory (Benjamin, 1988, 2002; Butler, 1995,
This article was published Online First October 29, 2020.
Guido Giovanardi, PhD, Emanuela Mundo, MD, and Vittorio
Lingiardi, MD, Department of Dynamic and Clinical Psychology, Sapienza
University of Rome.
Correspondence concerning this article should be addressed to Guido
Giovanardi, PhD, Department of Dynamic and Clinical Psychology, Sapi-
enza University of Rome, Via degli Apuli 1, 00185 Rome, Italy. E-mail:
guido.giovanardi@uniroma1.it
2004, 2011; Chodorow, 2005; Corbett, 2008, 2009; Dimen, 2013;
Ehrensaft, 2011; Elise, 1997; Fausto-Sterling, 2000; Goldner,
2014; Halberstam, 1998; Harris, 2008; Layton, 1998; Lingiardi,
2015; Silverman, 1992; see also González, 2019). These works
paved the way for a disentanglement of gender identity from
anatomy. As Peter Fonagy described: “The profound gender bias
of Freudian psychosexual theory also jarred in the context of the
feminist enlightenment of the second half of the twentieth century”
(Fonagy, 2006, p. 4). Theories on gender development thus gained
complexity, as the authors expressed that gender is a gradient, both
constructed and innate, and the result of a “soft assembly” (Harris,
2008). Gender was often described in paradoxical terms, encom-
passing the tension of its components: “a force field (of dualism)
. . . consisting not of essences, but of shifting relations among
multiple contrasts” (Dimen, 1991, p. 343); “a real appearance”
(Benjamin, 1995, 1998); and “a false truth” (Goldner, 1991).
The psychoanalytic literature on trans patients reflects these varied
conceptions of gender. Some authors (e.g., Chiland, 2000; Gutowski,
2000; Quinodoz, 1998, 2002), reverting to classical theory, have
offered accounts of very complicated trans patients who are resistant
to transference, lacking in self-reflection, totally absorbed by their
desire to surgically alter their body, “dominated by the concreteness of
the ‘acting out’” (Argentieri, 2009, p. 4), and in pursuit of a “mad
idea” (Chiland, 2009, p. 43). Among these authors, Colette Chiland
(2000) defined transsexualism as a condition similar to psychosis,
linked to a psychic activation of a terrifying primal scene— one
comprised of parental projections that compels children to desire to be
1
In this article we use the term trans as an umbrella term indicating
gender-diverse conditions, including transgender and gender–non-
conforming identities. Where necessary, we also use other identity
specifications (e.g., nonbinary, genderqueer).

239
 240 GIOVANARDI, MUNDO, AND LINGIARDI
the opposite gender. Similarly, Agnés Oppenheimer (1991) held that
at the core of transsexualism was a deep narcissistic wound inflicted
by a lack of parental recognition; she viewed trans identity as a
“screen identity”—a form of defensive après-coup or a “permanent
acting-out,” characterizing a condition similar to the “perverse orga-
nization” described by Chasseguet-Smirgel (1984) or Andre Green’s
“white psychosis” (Donnet & Green, 1973). Both Chiland and Op-
penheimer described trans patients as severely narcissistic and only
interested in the therapeutic alliance to the extent that it enabled them
to obtain acknowledgment of their “delusional conviction” (Oppen-
heimer, 1991) to be the opposite gender and to access reassignment
surgeries.
Over the last 20 years, a new analytic voice has emerged,
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highlighting the personal needs of trans people in therapy and
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acknowledging trans identities as viable subjective realities (Sa-
ketopoulou, 2014). This new position has aligned with changes in
the diagnostic field, as reflected by the new diagnosis of gender
identity disorder in the fourth edition of the Diagnostic and Sta-
tistical Manual of Mental Disorders (4th ed.; text rev.; DSM–IV–
TR; American Psychiatric Association [APA], 2000) and the 10th
edition of the International Statistical Classification of Diseases
and Related Health Problems (World Health Organization, 2004),
the less pathologizing diagnosis of gender dysphoria in the Diag-
nostic and Statistical Manual of Mental Disorders (5th ed.;
DSM–5; (APA, 2013), the discussion of gender incongruence in a
chapter on sexual health in the ICD-11 (Drescher, Cohen-Kettenis,
& Reed, 2016; Drescher, Cohen-Kettenis, & Winter, 2012), and
the Appendix “Psychological Experiences that May Require Clin-
ical Attention” in the Psychodynamic Diagnostic Manual-2
(PDM-2; Lingiardi & McWilliams, 2015; Mundo, Persano, &
Moore, 2018). The authors of these contemporary works have
successfully overcome the tension between gender identity and
anatomy, updating psychoanalytic thinking with knowledge ac-
quired from genetics and gender studies. Examples of this new
literature include the work of Anne Fausto-Sterling (2000, 2012)
on genetic findings that support a nonbinary understanding of sex
differences and Gayle Salamon’s (2010) work on the concept of a
“felt body.” Alessandra Lemma (2012, 2013), for instance, fo-
cused on the “embodied self” of trans people and their “need to be
seen” in the analyst’s mind not as “perverse,” but as “incongru-
ent”—mirroring their felt “incongruence at the level of the body”
(Lemma, 2013, p. 94). Similarly, Agvi Saketopoulou (2014) de-
scribed the risk for trans people of a “massive gender trauma”
caused by the experience of being misgendered by primary objects
and the internal experience of having a body misaligned to the self.
Analysts must be sensitive to this profound struggle of trans
patients and work to promote mentalizing and body acceptance in
these patients, while also acknowledging the reality of their felt
need to change their body. We now know that no parenting
techniques or therapeutic interventions can change the gender
experience of trans people. Following the brilliant contribution of
Melanie Suchet (2011), Saketopoulou wrote that “even as layer
after layer of psychic trauma, early experience, and unconscious
conflict are peeled away, gender remains unwavering” (Saketo-
poulou, 2014, p. 21). For Saketopoulou, hormonal treatments and
surgical interventions are not acting outs of unconscious fantasies;
rather, they provide trans patients with a new “bodily materiality”
that better fits their psychological experience. Recently, Oren
Gozlan (2018) explored the possibility for the analytic dyad to
explore this new materiality, inviting analysts to provide trans
patients with a transitional space (Winnicott, 1971) in which to
integrate a new sense of self and draw new meanings from their
dilemma. Gozlan (2018) criticized Saketopoulou’s emphasis on
the process of mourning:
no doubt, transitioning involves a series of mourning, but the trans-
sexual subject is not grieving a vagina, a penis, or breasts . . . but
rather the way in which the body becomes painfully implicated in a
secretive history . . . Transitioning involves a series of recurrent and
recursive experiences, both of loss and gain, that will allow the
transitioning person to claim a particular kind of history. (p. 21)
In the contemporary context, psychoanalysis is becoming more
“hospitable” for trans people, thanks to these new contributions,
together with the seminal work of Domenico Di Ceglie (1998, 2012),
which aims at depathologizing transsexualism with the notion of a
multidetermined “atypical gender identity organization”; Patricia El-
liot (2001), with her suggestion that therapists openly focus on the
subjective narratives of transgender clients; and Jay Prosser, who, in
Second Skins: The Body Narratives of Transsexuality (Prosser, 1998),
provides a remarkable autobiographical psychoanalytic reading of his
transsexuality and transition process. In recent years, research (e.g.,
Budge, 2013, 2015; Hunt, 2014) has documented an increase in trans
and gender—nonconforming individuals seeking psychotherapy or
counseling. In their study on a wide sample of trans people in the
United States, Grant et al. (2010) found that 75% of their sample had
engaged in therapy and an additional 14% intended to seek counseling
in the future. As the authors point out, in comparison, only 3% of the
United States population utilizes psychotherapy. To date, the reasons
why relatively more trans people seek therapy has not been studied
thoroughly; however, it seems that there are different motivations for
these patients, not all relating to gender issues (Bockting, 2009; Hunt,
2014; Korell & Lorah, 2007; Rachlin, 2002). Studies on the long-term
psychoanalytic therapy of trans patients are scarce and, to our knowl-
edge, none of the existing studies has been evidence-based. This
might be due to the lack of a valuable framework in which to assess
gender diverse people. To this end, it is our position that the PDM-2—
with its assessment tool, the Psychodiagnostic Chart-2 (PDC-2; Gor-
don & Bornstein, 2015; see also Lingiardi, McWilliams, Bornstein,
Gazzillo, & Gordon, 2015)—might be very useful for general psy-
chological assessment, as it includes aspects related to gender diver-
sity. Thus, the PDC-2 may be ideal for a longitudinal study of trans
persons’ changes in psychological functioning during long-term psy-
chotherapy.
In addition to the PDC-2’s comprehensive evaluation of psycho-
logical functioning, our clinician-based assessment—inspired by the
PDM-2 diagnostic framework— entailed the study of patient person-
ality and transference and countertransference patterns in the thera-
peutic dyad (Hilsenroth, Katz, & Tanzilli, 2018). The transference and
countertransference patterns of trans people in therapy are understud-
ied; however, these patterns may shed light on the complex uncon-
scious dynamics of the analytic encounter and provide new insight
into their underlying prejudices and biases (e.g., Hansbury, 2017; Raj,
2002). On the other hand, assessing the personality of trans people
using the Shedler Westen Assessment Procedure-200 (SWAP-200;
Westen & Shedler, 1999a, 1999b)— especially in a longitudinal per-
spective—is also informative and useful because, similar to the
PDM-2, the SWAP-200 emphasizes the subjective dimension, assess-
ing changes in relational, cognitive, and affective patterns that com-
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA
pose the entirety of personality (Lingiardi & Giovanardi, 2017; Lin-
giardi, Giovanardi, Fortunato, Nassisi, & Speranza, 2017). The
SWAP-200 and PDM-2 diagnostic tools were designed to measure
respondents’ ideas of who they are, rather than what they have. In this
sense, our clinical assessment paid particular attention to individual
patient characteristics, in order to grasp the specific personality fea-
tures of single patients within the group of individuals generically
classified under the (descriptive but not dynamic) diagnosis of gender
dysphoria. In particular, the SWAP-200, administered at different
stages of therapy, may enable clinicians to better detect patient
changes throughout the course of therapy (i.e., at the level of psycho-
logical processes, defense mechanisms, behaviors, and coping meth-
ods). Finally, we know that the evaluation of gender—nonconforming
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people can involve heavy bias, due to the use of inadequate measures.
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The SWAP-200 has been specifically tested for use with trans-
gender people, taking into account three areas of psychological
functioning: identity, relationships, and sexuality (Lingiardi &
Giovanardi, 2017). Lingiardi and Giovanardi (2017) used the
SWAP-200 to extract three personality factors from a sample of
trans persons (see Appendix A). The following clusters emerged:
healthy-functioning, depressive/introverted, and histrionic/extro-
verted. The healthy-functioning factor described trans persons with
good relational capacities and affect regulation. The depressive/
introverted factor described trans persons with general passivity
marked by fear of being abandoned/rejected, shame, a sense of
inadequacy, and a tendency to avoid social situations and relation-
ships. Finally, the histrionic/extroverted factor described trans
persons with sexual impulsivity, a lack of empathy, a tendency to
avoid intimacy, excessive use of physical attractiveness to gain
attention, and poor psychological insight. In the current study we
used these factors to track progress in the patient’s psychological
functioning and personality organization.
Similar to previous clinical works that have taken an evidence-
based approach to analyzing psychotherapeutic accounts (e.g.,
Albani et al., 2003; Lingiardi, Gazzillo, & Waldron, 2010; Lin-
giardi, Shedler, & Gazzillo, 2006; Roussos, Martin, Penedo, &
Muiños, 2018; see also Kächele, Schachter, & Thomä, 2012;
Slavin-Mulford & Hilsenroth, 2012), the present study aimed at
Figure 1. Research plan and personality trends. See the online article for the color version of this figure.
241
describing a single case of psychoanalytic psychotherapy using
both qualitative and quantitative methods. The qualitative ap-
proach drew on the analyst’s narratives and the quantitative ap-
proach used data collected from empirical instruments. In perform-
ing the research, we sought to describe the benefits and
complexities of the open and gender-affirming long-term psycho-
analytic treatment of a trans woman, Paola, that supported her in
key phases of her gender transition. The article will outline the
development of Paola’s psychological functioning and the thera-
peutic relationship, drawing on illustrations of the therapy and the
findings of measures collected at each stage.
Method
Therapy and Assessment
Paola is a White-Caucasian trans woman. In April 2009, at the
age of 38, she began psychoanalytic psychotherapy with the ana-
lyst. At the time of writing this article, Paola is still undergoing
psychotherapy with the same analyst, at a frequency of two ses-
sions per week. The analyst (EM) is a cisgender woman, psychi-
atrist, and psychoanalytically oriented psychotherapist with a
Jungian background enriched by a deep interest in the work of
several other authors: Jacques Lacan, Stephen Mitchell, Jessica
Benjamin, and Philip Bromberg, among others. The authors (GG
and VL) met EM in a clinical group in 2009, in which she reported
beginning treatment with Paola. What caught the authors’ interest
was that EM was very open about her countertransferential reac-
tions and resistances. Moreover, the clinical relationship seemed
very promising, as Paola’s reasons for entering therapy were not
limited to gender identity, but also included a motivation to work
on many aspects of her personality and relational world.
For Paola’s empirical assessment, the authors (GG and VL)
interviewed the analyst once a year from April 2009 onward. In
this article, we report four significant time points in the research:
after the first three sessions, in April 2009 (Time 0); 3 years later
(Time 1); 6 years later (Time 2); and 10 years later, in April 2019
(Time 3; Figure 1). In Table 1, we report the scores of the
 242 GIOVANARDI, MUNDO, AND LINGIARDI
Table 1
Assessment Plan
Measure T0 T1 T2 T3
SWAP-200 X X X X
PRQ X X X X
TRQ X X X X
PDC or PDC-2 X X
Note. SWAP-200 ⫽ SWAP-200 ⫽ Shedler Westen Assessment Proce-
dure-200; PRQ ⫽ Psychotherapy Relationship Questionnaire; TRQ ⫽
Therapist Response Questionnaire; PDC or PDC-2 ⫽ Psychodiagnostic
Chart or Psychodiagnostic Chart-2.
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SWAP-200, Psychotherapy Relationship Questionnaire (PRQ),
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and Therapist Response Questionnaire (TRQ) at each stage. More-
over, the analyst completed the Psychodiagnostic Chart (PDC;
Gordon & Stoffey, 2014) at Time 0 and the PDC-2 at Time 3; these
results are also reported in Table 1. For this article, the original
PDC was adapted to the PDC-2.
Measures
SWAP-200. The SWAP-200 (Westen & Shedler, 1999a,
1999b; see also Shedler, Westen, & Lingiardi, 2014) is a clinically
derived empirical diagnostic measure that has been shown to have
excellent retest reliability as well as good interrater, discriminant,
and convergent validities with a range of external criteria. To
complete the SWAP-200, the rater arranges a set of 200 person-
ality descriptive statements into eight categories, ranging from
those that fail to describe the patient’s personality (assigned a
value of 0) to those that are highly descriptive (assigned a value of
7), in reference to, when possible, a time period that includes the
previous 2 years. Higher ratings (i.e., values of 5, 6, or 7) are given
when an item’s content describes a characteristic that is central to
the patient’s personality and particularly pervasive across the pa-
tient’s many areas of life. Thus, the method yields a numeric score
from 0 to 7 for each of the 200 personality descriptive variables.
SWAP-200 items are written in straightforward, experience-near
language; statements that require inferences about internal psycho-
logical processes are written in plain language, not jargon. SWAP-
200 personality disorder (PD) scores, corresponding to 10 person-
ality disorder scales that are clinical prototypes of the DSM–IV–TR
(APA, 2000) and DSM–5 (APA, 2013) personality disorders, pro-
duce a nomothetic diagnosis of personality disorders. Moreover,
the SWAP-200 provides ideographic case formulations that are
useful for generating both specific personality assessments at a
given time and long-term evaluations of personality change or
treatment outcome (by replicating the assessment at subsequent
time points). Case formulations are obtained by aggregating the 30
highest ranked statements in a patient’s SWAP-200 description
(i.e., items with scores of 5, 6, and 7). This formulation takes into
account the three broad domains of psychological function de-
scribed by the SWAP-200 items, relating to: (a) motivations,
ideals, anxieties, and conflicts; (b) psychological resources; and (c)
experiences of self and others and relationships between one’s self
and others. In case formulations, SWAP–200 items are reproduced
essentially verbatim, with minor grammatical changes and con-
necting text, to yield a narrative description of the patient’s main
personality features. In the present research, as mentioned in the
introduction, we used three subtypes identified in a previous study
on a trans sample using Q-factor analysis: healthy-functioning,
depressive/introverted, and histrionic/extroverted (Lingiardi et al.,
2017; see Appendix A). At each stage, average scores of the items
comprising each subtype were calculated in order to verify which
subtype was most prevalent in Paola’s personality organization. In
the current work, these subtypes are described as SWAP-200
gender dysphoria (GD) factors and scored on a scale from 1 to 7.
PRQ. The PRQ (Bradley, Heim, & Westen, 2005; Westen,
2000) is a clinician-report questionnaire consisting of 90 items
measuring a wide spectrum of thoughts, behaviors, feelings, and
conflicts expressed by patients toward their therapist. Items are
derived from the clinical, theoretical, and empirical literature on
transference, the therapeutic or working alliance, and related con-
structs, and written in everyday language so that clinicians of any
theoretical orientation can use the tool equally, without bias.
Clinicians assess each item on a 5-point Likert scale ranging from
1 (not true) to 5 (very true). The PRQ factor structure used in the
current study was taken from the work of Tanzilli, Colli, Gualco,
and Lingiardi (2018) and comprises six transference dimensions
that are clinically and theoretically coherent: (a) hostile indicates
the patient’s feelings of anger toward the clinician and the ten-
dency to be oppositional, provocative, and dismissive; (b) positive/
working describes the patient’s tendency to collaborate with the
therapeutic work and construct a good clinical relationship char-
acterized by trust, affective attunement, and close connection; (c)
special/entitled indicates the patient’s tendency to make excessive
demands of the therapist to admire him/her and hold him/her above
other patients; (d) anxious/preoccupied describes the patient’s fear
of the therapist’s disapproval or rejection, need for excessive
reassurance, and dependent attitude toward the therapist; (e)
avoidant/dismissing describes the patient’s tendency to avoid
meaningful connection with or dependence on the therapist; and (f)
sexualized indicates the patient’s sexual attraction toward the
therapist.
TRQ. The TRQ (Betan, Kegley Heim, Zittel Conklin, &
Westen, 2003; Zittel Conklin & Westen, 2003), which is filled out
by clinicians, is designed to assess countertransference patterns in
psychotherapy. It consists of 79 items measuring a wide range of
thoughts, feelings, and behaviors expressed by therapists toward
their patients, ranging from relatively specific feelings (e.g., “I feel
bored in sessions with him/her”) to complex constructs, such as
projective identification (e.g., “More than with most patients, I feel
like I’ve been pulled into things that I didn’t realize until after the
session was over”). Items are from the clinical, theoretical, and
empirical literature on countertransference and related variables,
and are written in a straightforward manner, without jargon and
near to clinical experience, so that the instrument can be used
comparably by therapists of any orientation. Clinicians assess each
item on a 5-point Likert scale ranging from 1 (not true) to 5 (very
true). The TRQ factor structure utilized in the current work was
taken from the work of Tanzilli, Colli, Del Corno, and Lingiardi
(2016) and comprises nine countertransference dimensions: (a)
helpless/inadequate indicates feelings of inadequacy and incom-
petence and a strong sense of inefficacy; (b) overwhelmed/disor-
ganized describes an intense feeling of being overwhelmed by the
patient’s emotions and needs, as well as confusion, anxiety, or
repulsion; (c) positive/satisfying describes an experience of close
connection, trust, and collaboration with the patient; (d) hostile/
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA
angry describes feelings of anger, hostility, and irritation toward
the patient; (e) criticized/devalued describes a sense of being
criticized, dismissed, or devalued by the patient; (f) parental/
protective captures a wish to protect and nurture the patient in a
parental way; (g) special/overinvolved indicates that the patient is
very special, so much so that the clinician may show some diffi-
culty maintaining the boundaries of the therapeutic setting; (h)
sexualized describes the presence of sexual attraction toward the
patient; and (i) disengaged describes feelings of annoyance, bore-
dom, withdrawal, or distraction in sessions.
PDC-2. The PDC-2 (Gordon & Bornstein, 2015; Lingiardi,
McWilliams, Bornstein, Gazzillo, & Gordon, 2015), an updated
version of the PDC, is essentially an operationalization of the
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PDM-2 assessment. The PDC-2 aims at offering practitioners a
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concise and user-friendly diagnostic tool by combining the symp-
tom focus of the ICD and DSM with the full range and depth of
human mental functioning addressed by the PDM and PDM-2. The
PDC-2 comprises five sections. The first section, Level of Person-
ality Organization, asks clinicians to rate four mental functions in
their patient on a scale from 1 (severely impaired) to 10 (healthy):
(a) identity, or the ability to view the self in complex, stable, and
accurate ways; (b) object relations, or the ability to maintain
intimate, stable, and satisfying relationships; (c) level of defenses;
and (d) reality testing, or the ability to appreciate conventional
notions of what is realistic. Clinicians then score the patient’s
overall personality organization (psychotic, borderline, neurotic, or
healthy), considering their ratings of the four component scales
and their overall clinical judgment. The second section, Personal-
ity Syndromes (P axis), asks clinicians to rate relevant personality
patterns from 1 (severe) to 5 (high functioning). The third section,
Mental Functioning (M axis), asks clinicians to comment on their
patient’s mental functioning within four main domains: (a) cogni-
tive and affective processes, (b) identity and relationships, (c)
defense and coping, and (d) self-awareness and self-direction.
These four subscales are used to derive an overall personality
severity score. The fourth section, Symptom Patterns (S axis), asks
clinicians to describe the patient’s main symptom patterns among
psychotic disorders, mood disorders, and event- and stressor-
related disorders. The prevalent symptoms are rated on a 5-point
Likert scale ranging from 1 (severe) to 5 (mild). Finally, the fifth
section, Cultural, Contextual, and Other Relevant Considerations,
invites clinicians to add relevant information about the patient’s
social and cultural environment. In comparison to the original
PDC, the PDC-2 offers a wider assessment in every section,
including the evaluation of mentalizing abilities (on the M axis)
and sociocultural aspects (on the S axis).
Case Illustration of Paola
Personal History
Paola utilized masculine pronouns and adjectives to describe
herself during her childhood, and feminine pronouns and adjec-
tives after she turned 18. In this article, we replicate the same
age-based pattern, referring to Paola in masculine language forms
only up to her age of adulthood.
Paola grew up in a heavily dysfunctional family. His father was
a violent man, without a stable job, who forced Paola’s mother to
practice prostitution inside the family home. Paola’s father left the
243
house when Paola was 6 years old. When Paola turned 11, he was
sexually harassed before becoming a victim of repeated sexual
abuse from his paternal uncle. Gender dysphoria seemed to onset
around the age of 15, when Paola became very disturbed by his
male secondary sexual characteristics. Prior to that time, he had
thought he might be gay. Bodily changes at puberty and the
distress he suffered led him to rethink his identity. He felt “hor-
rendous, disfigured.” He would not leave his house— even to
attend school—without having removed every single hair from his
face beforehand. During this time, Paola’s family ignored his
persistent requests to see a psychologist. At the age of 16, Paola
attempted suicide by taking sleeping pills. When he returned home
from the hospital, his maternal aunt tried to convince her sister to
support the boy’s need for counseling. Paola’s aunt seems to have
been the only positive and supportive figure in his family; only a
few months later, she committed suicide.
At Age 18, Paola left home and began to prostitute herself,
following the advice of an older trans friend, aiming at earning
enough money to start her gender transition. By the age of 20, she
had earned enough money to undergo several plastic surgeries (but
not gender reassignment). Her mother was aware of Paola’s pros-
titution (as she continued to prostitute herself, too). During these
years, Paola experienced several episodes of physical abuse by
clients. In one such instance, she was abducted by three men in a
van, raped, beaten up, and abandoned on the highway, bruised and
scarred. Nonetheless, she managed to attend a fashion and design
master’s course, which led to a job offer from a well-known
fashion firm. Paola accepted the offer and moved to another city at
the age of 30. Five years later, being the victim of transphobia in
the workplace, she resigned (through an acting out) from her post.
She started to prostitute herself again, though in a safer environ-
ment (her apartment) and with richer clients. She started therapy at
the age of 38.
Time 0: Beginning of Therapy
Analyst’s perspective. When the analyst meets Paola at the
first session, she is surprised to see quite an attractive woman,
presenting in sober, elegant clothes. She admits that she expected
a more stereotypically hyperfemale trans person (from the referral,
she only knew that Paola was transgender; she also knew a bit of
Paola’s traumatic history). As soon as she starts talking, Paola
says: “I want you to know I have not done the sex reassignment
surgery” and “I’m here to break away from my mother.” Paola’s
mother is now confined to a psychiatric extended care unit for
bipolar disorder. Paola visits her mother regularly and takes good
care of her body and appearance. Paola displays severe dysmor-
phophobia, as she repeatedly undergoes painful and unnecessary
cosmetic surgeries—mostly on her face—to reshape her features in
a “more feminine” fashion. She describes these surgeries as a
“vicious circle” from which she cannot escape. Paola uses similar
words to describe her relationship with her mother. She calls her
almost 20 times per day, fearful of her mother’s rage if she does
not call. The first dream Paola brings to therapy is one in which she
violently beats her mother. The analyst feels a true sympathy for
Paola, with some big concerns about her source of income (pros-
titution). She admits she reacts a bit “superficially” (in her words:
“as if I was not interested in her gender identity, or wanted to show
an unconditional acceptance, no matter what”) to Paola’s initial
 244 GIOVANARDI, MUNDO, AND LINGIARDI

statement that she has not undergone gender reassignment surgery.
During the second session, Paola says that the analyst reminds her
of Barbra Streisand in the movie The Prince of Tides (Streisand,
1991), in which Streisand’s character is basically a psychiatrist
who treats her catatonic patient through the patient’s memories of
his brother. This association leads the analyst to work around the
theme of the “double” and Paola’s male body.
Empirical perspective. With regard to personality, as as-
sessed with the SWAP-200 and in relation to PD factors (Table 2
displays all results), at Time 0 Paola demonstrated an above
average high-functioning score of 58.89 (relative to the average T
score of 50), with obsessive (T score ⫽ 56.72), dependent (T
score ⫽ 53.95), and avoidant (T score ⫽ 52.47) personality traits
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
patterns were positive/working (3.25), anxious/preoccupied (2.77),
and avoidant/dismissing (2.22). Paola seemed able to talk openly
about difficult material, empathic toward the analyst’s feelings,
and attuned to the analyst’s communications. However, she
showed difficulty expressing anger or disappointment and needed
excessive reassurance, as she was uncomfortable imagining the
analyst caring about her and thus maintained distance in the
relationship. Similarly, the TRQ results show the prevalence of
parental/protective (3.17), helpless/inadequate (2.78), and positive/
satisfying (2.63) countertransference patterns. The analyst seemed
to want to protect her and felt parental feelings for her. She was
angry at people who hurt Paola, seemed to enjoy sessions with her,
and found the work with her quite exciting. However, she felt a bit

(see also Figure 1). incompetent and inadequate in her ability to help Paola compared
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In terms of SWAP-200 GD factors, at Time 0 Paola scored to other patients with different problems.
highest (3.92) on the depressive/introverted factor, followed by the
healthy-functioning (3.00) and histrionic/extroverted (2.25) factors
Time 1: 3 Years Later
(Table 3 and Appendix A). The prevalence of depressive aspects in
Paola’s personality at the beginning of therapy is evident in her Analyst’s perspective. During the first 3 years of therapy, the
case formulation, comprised of the 30 highest ranked SWAP-200 two main themes of the analytic work have been Paola’s relation-
items: ship with her mother and her dysmorphophobia. Paola has come to
realize that she has a distorted self-image, of which her external
Paola tends to feel unhappy, depressed, or despondent. She has appearance is a reflection. She violently struggles against this
difficulty allowing herself to experience strong pleasurable emotions
self-image. At the heart of her compulsive need to self-reconstruct
(e.g., excitement, joy, pride). She appears to find little or no pleasure,
satisfaction, or enjoyment in life’s activities and tends to be inhibited
there is the pain these surgeries cause to her body, especially to her
or constricted; has difficulty allowing herself to acknowledge or face. Following an “agreement” with the analyst, Paola has de-
express wishes and impulses and appears not to feel entitled to get or creased her number of aesthetic surgeries over the past years.
ask for things she deserves. In fact, she tends to deny or disavow own Simultaneously, she has become more involved in LGBTQ activ-
needs for caring, comfort, closeness, or to consider such needs unac- ism and started mentoring younger trans friends. Paola has de-
ceptable. She is preoccupied with the feeling that someone or some- clared that she does not want to undergo sex reassignment surgery,
thing has been irretrievably lost (e.g., love, youth, the chance for and she has begun to identify herself as a “trans/genderqueer”
happiness, etc.). She tends to use her physical attractiveness to an person. Either the development of her nonbinary identity or her
excessive degree to gain attention or notice. However, she has a decrease in dysmorphophobia have begun to release her from her
disturbed or distorted body image; she sees herself as unattractive and
claustrophobic maternal bond. She has begun to manage her sense
grotesque. She often feels guilty, ashamed, and embarrassed. She has
the fear she will be rejected or abandoned by those who are emotion-
of guilt and fear of punishment over no longer calling her mother
ally significant. Thus, she’s afraid of commitment to a long-term love several times a day and not being completely at her service.
relationship. Nonetheless, she’s empathic, sensitive, and responsive to However, she still feels that her weak and fragile mother would
other peoples’ needs and feelings and tends to elicit liking in others. perish without her help. In a dream presented at approximately this
Overall, she appears to be conscientious and responsible. point in the therapy, Paola lies in bed with her dead mother, while
in a corner her female cat eats spoiled food. Paola still has
Regarding transference and countertransference at baseline problems being in an intimate relationship. She has gradually come
(Figures 2 and 3), the PRQ showed that the prevalent transference to understand that she uses prostitution more than to simply make
a living, but also to defend against intimacy with potential part-
Table 2 ners. The analyst feels very satisfied with their working alliance,
SWAP-200 PD Factor Results although she remains concerned with Paola’s prostitution. She
acknowledges that she is relieved by Paola’s decision to forego sex
SWAP-200 PD factors (T scores) Baseline 3 years 6 years 10 years reassignment surgery. Paola, as well, frequently expresses her
satisfaction with the therapeutic alliance. During a session at the
Paranoid 32.68 30.42 29.43 38.58 end of the third year, she highlights the positive impact of the
Schizoid 49.35 45.12 41.65 37.91
Schizotypal 40.56 36.06 33.82 33.13 therapeutic relationship on her capacity to scale down the pressure
Antisocial 39.09 40.47 39.03 41.68 exerted by the maternal bond. She admits cheerfully: “Now that I
Borderline 45.70 39.02 35.41 36.90 come here twice a week, I can go there [to see her mother] only
Histrionic 41.65 40.68 37.43 37.83 once every two weeks!”
Narcissistic 39.16 36.59 37.84 41.67
Avoidant 52.47 48.73 47.03 43.81
Empirical perspective. At the end of the third year, the
Dependent 53.95 50.42 48.76 44.30 SWAP-200 PD scores showed a slight improvement in the high-
Obsessive 56.72 54.45 51.92 53.55 functioning factor, from 58.89 to 60.12. Accordingly, all person-
High functioning 58.89 60.12 70.52 75.22 ality disorder traits had decreased: the obsessive factor had de-
Note. SWAP-200 ⫽ SWAP-200 ⫽ Shedler Westen Assessment Proce- creased to 54.45, the dependent factor to 50.42, and the avoidant
dure-200; PD ⫽ personality disorder. factor to 48.73 (see Table 2 for all results).
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA
Table 3
SWAP-200 GD Factor Results
SWAP-200 GD factors M(SD) Baseline
Factor 1: Healthy-functioning 3.00 (2.56)
Factor 2: Depressive/introverted 3.92 (2.50)
Factor 3: Histrionic/extroverted 2.25 (2.90)
Note. SWAP-200 ⫽ SWAP-200 ⫽ Shedler Westen Assessment Procedure-200; GD ⫽ gender dysphoria.
Highlighted in bold are the highest scores per year.
In terms of the SWAP-200 GD factors, both the histrionic/
extroverted factor and the depressive/introverted factor showed a
slight decrease, with the latter remaining the highest factor,
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whereas the healthy-functioning GD factor showed an increase
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from 3.00 to 3.52 (see Table 3).
Regarding transference and countertransference, the PRQ
showed a decrease in anxious and avoidant transference pat-
terns and a slight increase in the working alliance and positive
transference patterns (see Figure 2). Finally, the TRQ displayed
an increase in positive/satisfying patterns and a decrease in the
overwhelmed/disorganized, helpless/inadequate, and parental/
protective patterns (see Figure 3).
Time 2: 6 Years Later
Analyst’s perspective. Having lived for some time in a non-
binary identity, Paola has, in the following years, developed an
increasingly definite feminine identity, becoming more aware that
her facial cosmetic surgeries have been mostly a kind of phobic
“displacement” from genital surgery. She now acknowledges that
Figure 2. Transference patterns (PRQ results). See the online article for the color version of this figure.
245
3 years 6 years 10 years
3.52 (2.45) 4.50 (2.15) 5.50 (1.51)
3.78 (2.36) 3.31 (2.46) 2.77 (1.96)
2.17 (2.44) 1.86 (2.21) 1.00 (1.76)
she uses prostitution to defend herself against romantic involve-
ment with partners, in addition to making money. She has entered
into various romantic relationships with men, but she has ended all
of these when the partners have asked her to stop working with
clients. She is aware that, with reassignment surgery, her prosti-
tution will end. Thus, not doing sex reassignment means perpetu-
ating the defense against intimacy that is acted out through pros-
titution. A dream in this period impresses the analyst for its
powerful imagery: in the dream, Paola finds a pack of sanitary
pads in her house. At first she is confused and does not understand
why the pads are in her home. Then she realizes that she has
undergone the reassignment surgery and she now has a vagina,
which is bleeding. She thinks that something must have gone
wrong with the surgery; however, she eventually realizes that she
is menstruating and everything is fine. The analyst highlights the
new meaning of “blood,” transposing it from its traumatic origin
(the result of a wound) to a new generative meaning (menstrual
blood). In the preceding years, Paola has made up her mind about
surgery. Initially, she had decided to undergo it in Thailand by a
 246 GIOVANARDI, MUNDO, AND LINGIARDI
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
Figure 3. Countertransference patterns (TRQ results). See the online article for the color version of this figure.
world-renowned specialist surgeon. However, this would have
been incredibly expensive and vexing. Her plan to travel to Thai-
land on her own and face all of the painful consequences of
surgery by herself—without the help of a friend—seemed to have
been informed by a dreamy pursuit of an ideal and perfect body
disconnected from her real needs and still contaminated with some
degree of dysmorphophobia (in addition to genital surgery, she
also wanted to redesign her nose and cheekbones). In fact, Paola
repeatedly postponed her trip in her mind and never booked an
appointment at the clinic. The analyst’s feelings toward surgery are
mixed. Overall, she worries that the result will never equal Paola’s
ideal representation of her female body.
Empirical perspective. At Time 2, with regard to personality,
the SWAP-200 PD scores showed substantial improvement in the
high-functioning factor, with a new score of 70.52. This marked an
increase of more than 1 SD from the beginning of therapy, indi-
cating clinically significant improvement. Accordingly, all person-
ality disorder factors continued to decrease: the obsessive factor
decreased to 51.92, the dependent factor to 48.76, and the avoidant
to 47.03 (see Table 2 for all results).
At the same time, in terms of SWAP-200 GD factors, the
healthy-functioning GD factor showed a substantial increase to
4.50 (see Table 3) and became the prominent factor in Paola’s
personality organization. Both the depressive/introverted and the
histrionic/extroverted scores decreased.
The PRQ scores consolidated the positive trend, showing a
further increase in the working alliance and decreases in the
anxious and avoidant transference patterns. Negative countertrans-
ferential patterns also decreased; however, there was a significant
increase in the parental/protective factor, perhaps reflecting the
analyst’s anxiety toward Paola’s gender reassignment surgery.
Time 3: 10 Years Later
Analyst’s perspective. In the preceding years, Paola enjoyed
a relationship with a very supportive and caring man for 2 years.
This relationship was the first in which Paola synthesized sexuality
and intimacy. With the help of her partner, she managed to change
her official identity documents. Analytic work in this period fo-
cused on working through the idealized feminine representation,
enhancing Paola’s mentalizing and acceptance of the reality of her
body, and weighing up the safest options to transform it. Reflect-
ing on the discomfort of being alone in Thailand, far removed from
home, Paola had finally decided to make use of a specialized
service in Italy, covered by the Italian Health Service, with all
visits and surgeries accompanied by a dear friend. Paola had
booked her genital surgery for the day of her birthday. For the
analyst, this shift from idealization to acknowledgment of her need
for support and safety marked a bold achievement in the analytic
work. A dream in this period displayed this new and freer identity:
in Paola’s bedroom (where she receives clients) her mother ap-
pears as a beautiful, young, and lively woman who helps Paola
renovate the room and arrange the walls and furniture. This mother
is a “good mother”— different to and (to a certain extent) far from
the dead one of the previous dream—who helps Paola acquire a
room (and identity) of “her own.” At this time, dysmorphophobia
seems to have ceased (it has been several years since Paola’s last
surgical intervention on her face). Paola is less active in mentoring
others and more concerned with her own needs. She is close to
getting a job in a famous theater as a make-up artist (a job for
which she is very well qualified). She also seems at ease with the
idea of getting old, no longer tormented by the feeling that some-
thing has been lost forever. When the analyst asked Paola for
permission to write down this clinical account, Paola showed
further evidence of trust and satisfaction with the work done. She
was very glad to provide her consent, claiming that she looked
forward to the possibility of the publication (and recognition) of
her history, which she hoped might motivate other trans people to
begin psychotherapeutic treatment. When the analyst told her that
the article would be edited to mask personal references, Paola was
a bit disappointed that she would not appear with her real name: “I
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA
understand, however I would have been proud to be a proven
witness to the benefits of therapy!”
Empirical perspective. With respect to personality at Time 3,
PD scores showed a further increase in the high-functioning factor,
now scoring 75.22. The obsessive factor showed a mild increase,
to 53.55 (however less than the initial 56.72), whereas dependent
and avoidant traits showed a further decrease, to 44.30 and 43.81
(see Table 2), respectively.
In terms of GD factors, there was an additional gain of 1 point
in the healthy-functioning score, which was now 5.50. On the
contrary, the other two factors had decreased: depressive/intro-
verted traits now amounted to only 2.77 and histrionic/extroverted
characteristics (with a score of 1.00) had almost disappeared from
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Paola’s personality organization (see Table 3). Paola’s case for-
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mulation in the follow up, based on the 30 highest rated SWAP
items at Time 3, significantly differs from the formulation at the
beginning of her treatment:
Paola is now capable of sustaining a meaningful love relationship
characterized by genuine intimacy and caring and to form close and
lasting friendships characterized by mutual support and sharing of
experiences. She tends to be conscientious, responsible, energetic, and
outgoing. She’s psychologically insightful and able to understand
herself and others in subtle and sophisticated ways. She seems now
capable of hearing information that is emotionally threatening and can
use and benefit from it. She appears to have come to terms with
painful experiences from the past and has found meaning in, and
grown from such experiences. However, sometimes she appears still
to want to “punish” herself, creating situations that lead to unhappi-
ness, or actively avoiding opportunities for pleasure and gratification.
She’s articulate and creative: able to see things or approach problems
in novel ways. Overall, she seems comfortable and at ease in social
situations, however sometimes she tends to feel ashamed or embar-
rassed, anxious and inadequate or inferior. Her work life seems to be
a bit chaotic or unstable. She happens to be competitive with others
(whether consciously or unconsciously) and to react to criticism with
feelings of rage or humiliation. She finds meaning in belonging and
contributing to a larger community and is able to find meaning and
fulfillment in guiding, mentoring, or nurturing others.
Transference and countertransference patterns at Time 3 con-
firmed the positive trend that emerged at Time 1 and Time 2. The
PRQ results indicated a consolidation of the working alliance (with
the highest score of 4.42) and a further decrease in the anxious
pattern, in parallel with a slight increase in the avoidant pattern
(maybe indicating that the dyad was beginning to approaching a
closure; see Figure 2). Similarly, the highest TRQ score was that
of a positive/satisfying countertransference, and there were
further reductions in the helpless/inadequate (now 1.25) and
overwhelmed/disorganized (1.18) patterns.
PDC-2 Assessment
The PDC-2 assessment, comparing the baseline to the 10-year
follow-up, showed improvement in all areas (see Appendix B for
all scores). As stated above, the PDM-2 diagnosis of gender
incongruence resides in the Appendix titled “Psychological Expe-
riences that May Require Clinical Attention.” In Paola’s case, from
the beginning of therapy onward, her gender incongruence was
never a matter of dysphoric feelings; thus, both PDC-2 adminis-
trations would deem her “healthy.” On the contrary, at the begin-
ning of therapy Paola presented severe impairment in her person-
247
ality organization, with problems maintaining stable relationships,
use of borderline defenses as acting outs (e.g., cosmetic surgeries
on her face), splitting and idealizing, and deficits in reality testing.
In line with the SWAP-200 results, Paola showed significant traits
of depressive, anxious, dependent, and obsessive personality syn-
dromes. In the 10-year follow-up, she showed a healthy personal-
ity that was free from pathological traits, except for mild depres-
sive traits. With regard to the PDM-2 M axis, all aspects of mental
functioning were significantly improved, with increases in men-
talizing, self-esteem, resiliency, and coping. Improvement was
also confirmed in the S axis, where—from the initial psychody-
namic diagnoses of severe body dysmorphic disorder, posttrau-
matic stress disorder, and major depressive disorder—Paola
showed only mild traits of depressive and dysmorphic disorders.
Discussion
Paola’s case appears to depict a quite successful psychoanalytic
therapy that led to several improvements in her psychological
functioning, affective relationships, and social adaptation. From
the PDC-2 and SWAP-200 assessments over the study period, we
observed a progressive reduction in her pathological traits. At the
beginning, Paola showed the effects of her highly traumatic his-
tory, with traits of a dependent and obsessive personality (from the
SWAP-200), depressive and anxious disorders, severe dysmorpho-
phobia, and the use of borderline defenses (from the PDC-2).
During the 10 years of treatment, the therapeutic work progressed
through several stages characterized by different analytic themes.
In the first three years, from Time 0 to Time 1, the therapeutic
work focused on Paola’s release from her sense of constriction in
her relationship with her mother and on her distorted self-image,
which was the target of compulsory self-aggression. Paola man-
aged to free herself from some of her guilt over not being at the
service of her mother and she showed an important reduction in
dysmorphophobic acting outs. Subsequently, from Time 1 to Time
2, the main theme was Paola’s acknowledgment of two defensive
aspects: her use of prostitution as a means of avoiding intimacy
and her displacement of her dysphoric feelings about her genitals
to her face (as evidenced by her cosmetic surgeries). Finally, in the
last stage of therapy, from Time 2 to Time 3, Paola succeeded in
de-idealizing her representation of femininity and mentalizing the
limits and reality of her body.
Accordingly, the SWAP-200 showed a significant increase in
Paola’s high-functioning score, highlighting an improvement in emo-
tion regulation, sense of identity, and affective and relational patterns.
As the SWAP-200 scores point out, in parallel with her development
of a stable feminine identity, Paola also developed a healthy person-
ality with some obsessive traits; furthermore, avoidant, dependent,
and depressive aspects left the stage, enabling her to improve her
mentalizing and enjoy intimacy in relationships. These developments
were accompanied by progress in the therapeutic relationship, attested
to by our empirical investigation. Indeed, Paola’s progress paralleled
the analyst’s progress in developing her disposition toward transgen-
derism. The analyst’s initial feelings of inadequacy and a kind of
masked stigmatization (i.e., an expressed hyperacceptance) trans-
formed into acceptance and resolution of her parental preoccupation
regarding gender reassignment surgery, enabling her to better manage
her countertransferential anxiety. At the beginning of therapy, in fact,
the analyst—although aware even in the first few sessions of a
 248 GIOVANARDI, MUNDO, AND LINGIARDI
positive therapeutic bond and the possibility of a working alliance—
seemed to have some negative feelings related to the therapeutic
relationship. At baseline, the countertransference patterns showed
strong feelings of inadequacy, fragility, and disorganization. In this
disposition, perhaps characterizing fear of the therapeutic bond with a
trans patient, we can read some of the prejudices and biases of
historical psychoanalytic interpretations. When the analyst first heard
the word “transgender” from the referral, she admits that the first
image that came to her mind was that of a very challenging patient—
one who would be difficult to reach and demanding. Paola’s initial
transference patterns seem to reflect these feelings: positive trust in
the working alliance was accompanied by insecure (both anxious and
avoidant) relational patterns. However, as reported at Time 1 and
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Time 2, the dyad showed important improvements over time, with
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decreased negative feelings in both participants and the development
of a strong alliance. The endurance of this positive trend was verified
over the 10-year time period, at the end of which both the PRQ and
the TRQ results showed a strong alliance and high satisfaction with
the work.
From the analyst narrative, we can highlight some key themes in
the progress of this therapeutic relationship between a trans woman
patient and a cis woman analyst. In this dyad, femininity and the
development of a feminine identity seemed to dominate much of the
analytical work. At first, Paola’s feminine identity seems to have had
the characteristics of a trauma-driven substitute identity that was
developed late— during adolescence—following sexual abuse by her
uncle. In Oppenheimer’s (1991) words, this was an après-coup screen
identity, marked by profound terror and a hatred of masculinity. On
the field of her body, Paola seems to have fought an actual war against
male features: in adolescence, he removed his facial hair one follicle
at a time and, in adulthood, she compulsively underwent painful and
unnecessary cosmetic surgeries in order to modify her masculine
facial features. According to Paola, it was her face that suffered the
terrible consequences of her being beaten in her 20s. Thus, Paola
seemed to locate her masculinity in her face, rather than her penis,
which was central to her sexual (and professional) activity and which
she did not feel the need to remove. On a symbolic level, the face
inevitably evokes the concept of a mask—a persona or identity. For
Paola, her face was the battlefield between—in Jungian terms (see,
e.g., Jung, 1967)— her persona and shadow archetypes, with her
shadow encapsulating all of the masculine traits that she found terri-
fying and abusive. Paola’s gender identity representations, marked by
strongly traumatic figures (i.e., an abusive father who forced Paola’s
mother to prostitute herself), seems to have been ravaged by what
Chiland (2000) defined as a “terrifying primal scene”—the basis for
Paola’s need for reparation. In her prostitution activity—an undeni-
able sign of enmeshment with the maternal figure—she usually per-
formed in active and “masculine” roles, reenacting abusive scenes:
with clients Paola became not only her mother, but also her uncle. In
this respect, Paola’s initial declaration in therapy was significant: “I
want to let you know I am not operated!” Among the first things Paola
brought to therapy was her body— her sexed body, her penis; a body
she took care of meticulously. When Paola spoke about her respon-
sibility in managing her mother’s house, the analyst naturally elabo-
rated the equation “maternal house ⫽ patient’s body,” focusing on the
enmeshed mother—son/daughter relationship, which Paola exposed
in the first session with her request to “break away” from her mother.
Paola could not tolerate that maternal house being seen as messy and
untidy; every detail needed to be perfect, in order to compose a
perfect— unreachable and persecutory—feminine image. The first
dream brought to the analysis, in which Paola violently beat her
mother, is emblematic of this ambivalent relationship with femininity.
Over time, however, Paola passed through a period of identity
indeterminacy and genderqueer identification— described by the
analyst as a proper transitional space in which Paola incrementally
experimented with different possibilities for her gender identity—
and finally elaborated a feminine identity unburdened by the
weight of her past trauma. She overcame her dysmorphophobia
and freed herself from the claustrophobic maternal bond. Paola
developed a new feminine identity, released from the ideal figure
of perfection that had been built up in opposition to the “dead
mother” so eloquently presented in her dream. We think that, in
this process, it was particularly important that Paola came to
acknowledge the analyst (and the analytic space) as a container—a
good mother figure, in contrast to the deficits of her biological
dead mother. This newly developed trust was evidenced by Paola’s
reporting to the analyst that, since beginning therapy, she felt more
free in her decision to not visit her mother. A key turning point was
also her eventual understanding of the defensive and displacing
nature of her need to surgically redesign her face. Through men-
talizing the limitations of her actual body, Paola, in line with
Saketopoulou’s (2014)theories, gave up her imago of unreachable
femininity not by reverting to a male identity, but by developing a
personal and more free feminine identity.
It is very interesting, though, that starting from premises that
seem to confirm— on the basis of the traumatic etiology of Paola’s
gender nonconformity—the classical psychoanalytic pathologizing
stance, Paola was not resistant to transference. On the contrary,
and confirmed by the empirical assessment, there was a strong
therapeutic alliance between Paola and her analyst. Whereas the
initial unconscious aim of the analyst might have been to prevent
surgical gender reassignment (in this regard, it is interesting to note
that the parental and protective countertransference patterns
showed a significant increase at Time 2, in parallel with Paola’s
resolution to perform surgeries, as if the parental need to protect
the patient gained intensity in the face of the appearance of the
surgical possibility), with time, countertransferential anxiety de-
creased significantly and surgical operations became a focus of the
analytical work, with the aim of developing Paola’s more inte-
grated identity2 that would guarantee her access to intimacy in
relationships, free from phobic defenses.
We believe that if analysts succeed in offering trans people a
true recognition of their identity and their body— both actual and
perceived—they may use psychoanalysis as a tool for these pa-
tients’ deep personal evolution. As Winnicott (cited by Gozlan,
2018) states, “we can observe the vicissitudes of transitional phe-
nomena but we can never predict or control them.” With trans
patients, we agree with Danielle Quinodoz’s (1998) suggestion
that analysts should assume a countertransferential position of a
parent who does not yet know the sex of their offspring. Gender
transition paths are full of tension, fear, and anxiety; patients on
this journey must resymbolize and renarrate their own origins,
2
With this we do not wish to imply that a binary gender identity is more
“integrated” than a non-binary identity, nor that a gender non-conforming
person needs surgery to be more complete. Paola’s feminine identity was
more integrated in the sense that it synthesized sexuality and intimacy,
releasing her from her trauma-driven defensive use of prostitution.
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA
passing through a complex web of meanings and signifiers in a
constant tension between internal and external perception. Ana-
lysts should provide space for their patients to amplify and under-
stand these new meanings. To do so, they must be able to tolerate
the anxiety of the as-yet unknown and altogether not-knowable.
Single case studies present many limitations, and this study is no
exception. We can only infer that Paola’s improvements were due
to her treatment (and not to her history, maturation, life events, or
the like); we have no evidence regarding the efficacy of the
therapy, nor could we study the effects of particular interventions.
Moreover, the patient displayed a very good disposition toward the
therapist (i.e., a strong therapeutic alliance) throughout the entire
course of therapy; this may represent a potential bias in general-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
izing the successful outcomes, due to the specific transferential and
This document is copyrighted by the American Psychological Association or one of its allied publishers.
countertransferential patterns involved. In addition, we adminis-
tered our measures to the clinician—the person treating the pa-
tient—and cut out the patient’s direct contribution to the research.
We must therefore consider the possibility of further limitations
related to the social desirability reporting of the analyst. Never-
theless, for this in-depth description of a long-term therapeutic
relationship with a gender nonconforming patient, we considered
the analyst’s point of view, in all of its sincerity and openness, a
highly informative and suggestive perspective on the complexities
of psychoanalytic work with patients presenting gender diversity.
摘要
对性别改变患者的精神分析描述在文献中是少见的. 对这些患者进行
精神分析会受历史偏见所累,这些偏见导致了对性别多样性的粗浅病态
的诠释. 本文描述了一个长程精神分析心理治疗,其对于变性采取了开
放和肯定态度. 该患者是一位跨性别成年女性,名叫保拉,当时正处于决
定接受变性手术之前的关键岁月里. 通过分析患者的认同和梦境,此篇
精神分析报告关注了她的转变之路的发展过程. 此研究阐明了保拉的
心理功能和治疗关系,通过临床描述并实证测量了保拉的人格以及不同
阶段治疗关系中的移情反移情模式. 结果显示了对变性患者进行精神
分析治疗的收益和复杂性,在他们转变旅程的关键阶段.
关键词: 案例研究, 人格评估, 精神分析过程, 反移情评估, 变性
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 252
SWAP-200 GD-Factors With Personality Profiles (Lingiardi et al., 2017)
Q factors
1. Healthy-functioning
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This document is copyrighted by the American Psychological Association or one of its allied publishers.
2. Depressive-introverted
3. Histrionic-extroverted
Note. SWAP-200 ⫽ Shedler Westen Assessment Procedure-200; GD ⫽ gender dysphoria.
GIOVANARDI, MUNDO, AND LINGIARDI
Appendix A
Personality Profiles of the SWAP-200 GD-Factors
SWAP-200 profiles
Tends to be conscientious and responsible (item 175); is able to use his/her talents, abilities, and energy effectively
and productively (2); and to assert him/herself effectively and appropriately when necessary (63). Generally finds
contentment and happiness in life’s activities (101) and is able to find meaning and satisfaction in the pursuit of
long-term goals and ambitions (196): enjoys challenges and takes pleasure in accomplishing things (19). Is
articulate, can express self well in words (92). Tends to express affect appropriate in quality and intensity to the
situation at hand (106). Tends to elicit liking in others (51). Appreciates and responds to humor (68). Is
empathic, sensitive, and responsive to other peoples’ needs and feelings (59); and is capable of sustaining a
meaningful love relationship characterized by genuine intimacy and caring (32).
Tends to feel ashamed or embarrassed (86) and to avoid or to be shy or reserved in social situations (60) because
of fear of embarrassment or humiliation (124). She/he becomes attached quickly or intensely and develops
feelings, expectations, etc. that are not warranted by the history or context of the relationship (11). She/he has
fear she/he will be rejected or abandoned by those who are emotionally significant (98); tends to be overly
needy or dependent; requires excessive reassurance or approval (77): generally she/he tends to feel she/he is
inadequate, inferior, or a failure (54). Tends to be anxious (35), unhappy, depressed, or despondent (189), and
she/he tends to use his/her psychological or medical problems to avoid work or responsibility (whether
consciously or unconsciously) (13); Has difficulty acknowledging or expressing anger (25). Tends to get drawn
into or remain in relationships in which she/he is emotionally or physically abused (26). Has trouble making
decisions; tends to be indecisive or to vacillate when faced with choices (180).
Tends to use his/her physical attractiveness to an excessive degree to gain attention or notice (97); Fantasizes about
finding ideal, perfect love (128); Tends to be overly needy or dependent; requires excessive reassurance or
approval (77). Appears afraid of commitment to a long-term love relationship (158); Tends to choose sexual or
romantic partners who seem inappropriate in terms of age, status (e.g., social, economic, intellectual), etc (181);
Tends to be sexually possessive or jealous; tends to be preoccupied with concerns about real or imagined
infidelity (80); Tends to deny or disavow own needs for caring, comfort, closeness, etc., or to consider such
needs unacceptable (159); Tends to be anxious (35); Tends to think in concrete terms and interpret things in
overly literal ways; has limited ability to appreciate metaphor; analogy; or nuance (75); Has little psychological
insight into own motives, behavior, etc.; is unable to consider alternate interpretations of his/her experiences
(148); Tends to repress or “forget” distressing events, or to distort memories of distressing events beyond
recognition (152); Appears unable to describe important others in a way that conveys a sense of who they are as
people; descriptions of others come across as two-dimensional and lacking in richness (41)
(Appendices continue)
 TRANSGENDER PSYCHOANALYSIS: THE CASE OF PAOLA 253

Appendix B
The PDC-2 Assessment

PDC-2 Assessment at Baseline and at the Follow Up (10 Years Later)

PDC-2 sections Baseline (Time 0) Follow up (Time 2)

Section 1: Level of Personality Organization

Level of personality organization 4 (moderate) 9 (healthy)
Identity 5 9
Object relations 3 8
Level of defenses 4 8
Realityt 4 10
Overall personality organization 5 (borderline) 9 (healthy)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Section 2: Personality Syndromes (P axis)

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Depressive 2 (severe/moderate) 5 (high-functioning)

Dependent 2
Anxious-avoidant and phobic 3 (moderate)
Obsessive-compulsive 2
Section 3: Mental Functioning (M axis)
Level of mental functioning 4 (mild impairments) 5 (healthy)
Capacity for regulation, attention, and learning 4 4
Capacity for affective range, communication, and understanding 4 5
Capacity for mentalization and reflective functioning 3 5
Capacity for differentiation and integration (identity) 3 5
Capacity for relationships and intimacy 3 4
Self-esteem regulation and quality of internal experience 3 5
Impulse control and regulation 3 5
Defensive functioning 3 5
Adaptation, resiliency, and strength 4 5
Self-observing capacities (psychological mindedness) 3 5
Capacity to construct and use internal standards and ideals 3 5
Meaning and purpose 4 5
Overall level of personality severity 40 (mild impairments) 58 (healthy/optimal)
Section 4: Symptom Patterns (S axis)
Body dysmorphic disorder (dysmorphophobia) 1 (severe) 5 (healthy)
Complex posttraumatic stress disorder 2 —
Major depressive disorder 3 (moderate) 5
Psychological experiences that may require clinical attention: Gender incongruence 5 5
Note. PDC-2 ⫽ Psychodiagnostic Chart-2.