Psychoanalytic Inquiry

A Topical Journal for Mental Health Professionals

ISSN: 0735-1690 (Print) 1940-9133 (Online) Journal homepage: http://www.tandfonline.com/loi/hpsi20

Understanding Gender Through the Lens of

Transgender Experience

Jack Pula M.D.

To cite this article: Jack Pula M.D. (2015) Understanding Gender Through the
Lens of Transgender Experience, Psychoanalytic Inquiry, 35:8, 809-822, DOI:
10.1080/07351690.2015.1087289

To link to this article: https://doi.org/10.1080/07351690.2015.1087289

Published online: 14 Dec 2015.

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Psychoanalytic Inquiry, 35:809–822, 2015
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
ISSN: 0735-1690 print/1940-9133 online
DOI: 10.1080/07351690.2015.1087289

Understanding Gender Through the Lens of Transgender

Experience
Jack Pula, M.D.

There is constant pressure on 20th-century psychoanalytic paradigms concerning gender and sexu-
ality, leading to ambiguity in theoretical constructs of, and therapeutic approaches to, gender. The
ongoing destructive notion that transgender people are inherently abnormal, perverse, and psychotic
is an epistemological problem that warrants scrutiny and correction in the field of psychoanalysis.
This article explores a nuanced set of transgender experiences juxtaposed with the author’s psycho-
analytic encounters as therapist, analysand, and analyst-in-training, in an effort to elaborate on
transgender subjectivities. Categories are woven, unraveled, and rewoven in the face of personal
realities and the author’s relationship to gender over time.

As a psychiatrist and psychoanalyst-in-training who is in the midst of a gender transition

from female to male, I am honored to contribute to this issue on gender. My experiences as a
clinician, a transgender person, a patient, and an advocate have lent me a unique perspective
on gender. I have shared my experiences in several speaking venues; I needed to hear myself
tell my story many times in many ways before having the courage to publish it. Also, I have
found that articulating gender experiences in words is inherently clunky—impossible to do
without built-in error. Spoken and written language is imperfect, despite the premium
analysts put on words. I hesitate to concretize my gender experience in printed words that
I may later wish to revise. Gender/gender identity is such a nuanced experience, both
relational and individual, that one can always learn and understand evermore about how
one’s gender works inside and out. After much struggle, I have concretized my gender in my
body in a way that has resulted in great relief and improvement of my inner and outer
worlds. I am allowing myself the flexibility to revise my experience of gender and my
relationship to gender over the course of my life. This rich and complex, yet frequently
misunderstood process deserves to be put into words, however imperfect and imprecise they
may turn out to be.
With this in mind, I share a series of personal reflections highlighting experiences that I hope
will enrich clinical thinking on gender and gender identity. Transgender is a phenomenon that
remains misunderstood, controversial, and anxiety-provoking in the culture at large, especially in
the field of psychoanalysis.

Jack Pula, M.D., is a psychoanalytic candidate at the Columbia University Center for Psychoanalytic Training and
Research, a faculty member at the Columbia University Division of Gender and Sexuality, and member of the American
Psychoanalytic Association Committee on Gender and Sexuality.
810 JACK PULA

TOMBOY

Everyone knows a tomboy. We have been around for centuries. How many child analysts have
had a tomboy on their rug, and how many adult analysts have treated grown tomboys on their
couches? How do analysts experience such children and adults? How do those patients experi-
ence their analysts? I saw no therapists as a child, and I often have thought that was a blessing,
because who knows what they would have made of me or done to me. As an adult I have had
two analysts, one pretransition and one during transition, a change in treatment that taught me
about the power of analysis to both heal and harm.
The collective clinical literature across psychological and medical disciplines does not help a
clinician predict if a child tomboy patient will become a typically or atypically gendered adult.
(Neither does the literature help one discern who will become a gay person or a straight person
or a bisexual person.) Transgender research has lacked evidence of clear predictive signals that
differentiate between those whose gender dysphoria will persist and desist past childhood
(Drescher, 2014). What is a parent or an analyst to do? Importantly for me, what is a tomboy,
then butch adult and candidate analysand, to do?
When I was growing up, I was a cute and well-liked tomboy. For the most part, people did
not make fun of me. Unlike natal boys who feel and act like girls, many tomboys, myself
included, are not teased as youngsters. However, childhood and adolescence can be brutal for
those who are bullied. I have heard accounts from my patients, and the literature confirms, that
LGBT youth are more likely to be bullied (Kosciw, 2012). I remember the brutal rape and
murder of Brandon Teena, a transgender male, twenty years ago (Halberstam, 2005). I have
shouldered my own adult fears of being raped, assaulted, or killed by men who may take offense
when learning of my transgender status. Luckily for me, I have not been physically or sexually
assaulted, though I have been in frightening situations where I feared severe violence. And
although I was not bullied in childhood or adolescence, I carried around an inner bully— shame
about my gender and sexuality— that I did not deal with consciously until recent years. Perhaps
part of the reason why I was not bullied as a child had to do with the reality that boys and men
are idealized in our culture, and that masculinity is admired as a symbol of strength and
aspiration. When I was a child in the 1970s, women were gaining new ground, especially in
the world of sports, where my own masculinity was able to brew without causing alarm or
suspicion (Harris, 2000). Perhaps tomboys had a unique pass from pediatrics and culture along
the lines: “It’s just a phase,” or “It’s a normal part of childhood.” I felt I was given such a pass.
As a kid who liked sports and the rougher edges of fun, and who eschewed dolls and pretty
things, I was able to find relative freedom to be myself in my family, my school, and my
neighborhood. I experimented as much as I could with typical feminine expression, especially in
my adolescence when I grew my hair long and got a perm. But I struggled internally and
relationally with gender without anyone seeming to notice.
When I was first coming out as trans to myself and my first analyst, I spoke about trying to
untangle the complicated knots of my family life and my gender expression in the context of
being a psychoanalytic candidate and a patient. I faced internal and external pressures to
decipher the analytic meaning of growing up as a tomboy, as well as understanding my shame
about gender. To date, I cannot claim to have parsed out a full, dynamic understanding of why I
took on masculinity as a child and an adult. I have argued with analysts about the need to know
when and if seeking such complete understanding is fair or helpful or traumatic (Corbett, 2011).
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 811

I have pointed out that we don’t ask cis-gendered people to go through such exploration before
identifying as man or woman. However, as a person in transition and as a clinician helping trans
people, I know that understanding and reworking one’s own narrative can be an essential
ingredient for sustained wellness and wise decision-making, especially regarding transition
decisions. I have progressed from fear and shame in the face of analysis to embracing curiosity
about how gender identity stands as a matrix of defenses, identifications, projections, introjec-
tions, and affects, while serving as a buffer and a major conduit of human interaction. As I have
moved through my gender transition, through the transition from one analyst to another, halfway
through psychoanalytic training, and through the early years of being a parent, I have learned to
embrace the little tomboy in me with less shame, less fear of inner and outer persecution, less
need to defend, and more awareness of how this male identity may have sprung from multiple
sources, including biology, culture, and my need to find joy and safety in a complicated family
dynamic.
One of my earliest memories is telling a cousin that I would pray on a mountaintop to God to
make me into a boy. Another early memory is going into the hospital at age three for hernia
repair and being greeted by my father upon discharge with a boy dress-up doll to help me learn
how to button vests and tie shoestrings. I have never verified that memory. It could be accurate,
is certainly imbued with fantasy, and could be a minor or massive distortion. I prefer preserving
the precious memory of my father understanding me in a very sophisticated, special, and
nonverbal way.
The memory of the boy dress-up doll surfaced in my first analysis, where I also spoke for
the first time of my secret wish that I was really an intersex person, rather than transgender,
and that I had really gone into the hospital at age three to have my sex changed from male to
female to correct a chromosomal or anatomical defect. I desperately wanted a biologically
identifiable cause for why I was who I was. I read Jeffrey Eugenides’s book, Middlesex (2002),
twice and was overcome with emotion when the protagonist charged off into life as a man after
a turbulent medical workup helped him understand his intersex genetics and remarkable family
history. After discussing my intersex fantasy with my analyst for some time, I obtained my
medical records from 1974 documenting my hernia repair, and sort of proving to me that my
birth sex was girl. I say “sort of” because the faint print, scant medical record, and illegible
writing undermined my confidence in this documentation and let part of me continue wishing
for an intelligible and known biological explanation that would make sense to me and to
others.
Like many trans-masculine kids, I identified with the boys in school and on television. I
wanted to be Arthur Fonzarelli of Happy Days, Bo Duke from Dukes of Hazard, Ricky Stratton
of Silver Spoons, and Theo Huxtable of The Cosby Show. Now, as a parent to a preschool-aged
daughter, I am struck by my admiration for one of her blond-haired boyfriends who dresses as I
sometimes did when I was his age. I have looked at this child and known my own jealousy of his
boy-gendered cuteness that I was frustrated in trying to enliven in my own childhood. He speaks
to my tomboy from four decades ago. During my childhood, I had girlfriends and boyfriends. I
was liked at my school. But my earliest memories were of my friendships with boys, my love for
denim jeans, bikes, baseball hats, and all things boy. I hated ballet and opera, things my father
loved, though today I pine for those art forms and realize that had I been born a boy I would
have sought them out. But as a tomboy girl, I could never enjoy those rigidly gendered, yet
uniquely gender-crossing activities. Today, I am certain that the cultural and my self-imposed
812 JACK PULA

exclusion from these gender-loaded activities contributed to deep pain that joined with other
pains and joys to create a unique affective, mental, and physical symbolic matrix through which
my character, including my gender identity, evolved.

PSYCHOANALYSIS

When I was a first-year psychiatry resident at age thirty-four, I began learning about psycho-
analysis. I had assumed I would become a psychiatrist on an inpatient unit or an Assertive Care
Treatment team, a model of care that attracted me because of its commitment to serving indigent,
disenfranchised, mentally ill people. As a former antipoverty activist who worked in community
mental health with chronically mentally ill and homeless people, I had assumed I would take up
this type of work. But I was quickly attracted to the intellectual rigor of psychoanalytic thinking
and the empathic capacities I gleaned from exposure to clinical psychoanalytic work.
I entered my own psychoanalytic psychotherapy, as many New York psychiatry resi-
dents do. I was passionately taken with this pursuit, feeling I had finally arrived at
something more meaningful than any previous schooling or training. But learning about
psychopathology, psychoanalysis, and one’s inner world as a psychiatry resident or psy-
choanalytic candidate is inherently daunting, if just for the paranoia this situation evokes.
The clinician patient is a specific kind of patient whose trajectory of training, personal
growth, healing, and self-knowledge impacts resilience and openness with self and analyst
or therapist. It was not just my atypical gender identity that my therapist and I looked to
understand, but also the myriad of outer and inner life dynamics that made me who I was.
The psychological road ahead was to be painful for me for many reasons.
Being a butch woman in psychiatric training is uncommon. I looked around, as I still do,
trying to find other butch people who were not anatomically male from birth. There aren’t many.
My experiences in clinical settings were fraught with gender dysphoria for me and confusion for
my patients. I was able to use my psychotherapy to talk about this most painful part of my life,
something I had held inside as a dark secret for many years. As my then therapist empathically
and patiently said, “You have been dealing with this for a very, very long time.” With that
simple, but affectively resonant statement, I opened into the most profound discoveries of my
mind and body.
I pursued academic interest in psychoanalysis through fellowships at Columbia University
and New York University, and ultimately was accepted to Columbia University Center for
Psychoanalytic Training and Research. I started a private practice and a one-year fellowship in
Emergency Psychiatry, professional work that connected me to disenfranchised communities,
diverse patient populations, and public service consistent with my long-held values. I was
thrilled to have a burgeoning career that gave me freedom to pursue all these interests and
provide me a decent living.
After four years of psychotherapy, I began coming out more clearly to myself as transgender,
a reality that I had fought off and felt deep shame over. In my fifth year of treatment, I converted
to psychoanalysis, four times a week. I was thrilled and I found that year to be crucial; however,
I was not aware that my analyst had doubts about having me use the couch. To this day, I do not
understand my first analyst’s unease. My analysis was already ongoing prior to use of the couch,
with a plump erotic transference, and enough other transference to fuel years of analysis. The use
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 813

of the couch, frequency of sessions, lack of eye contact, and ripe transference—cherished
facilitators of psychoanalysis—finally allowed me to access my body as a transgender person.
Yet, I unexpectedly landed in an impasse with my first analyst. As I continue my psychoanalytic
training and my transition, I remain haunted by that first analysis and its derailment.
Unfortunately, my potential gender transition was the crucible of the impasse. I moved toward
transition, but my analyst thought I was not ready. In retrospect, I believe my analyst thought I
was enacting a sadomasochistic dynamic in which I was forcing the analysis off track, away
from analyzing my longing for and fears of deep, desirous love, in favor of a sexualized,
gendered, bodily transformation as a way of acting out an erotic transference. My erotic
transference took many forms and exposed multiple fault-lines. I fantasized that my analysts
would lie with me and wrap themselves around me to hold in all that was seeping and squirming
out. Those fantasies of containment and love originated from an unfulfilled need from early life,
but I came to understand them as also portraying a unique shade of need, one painted by the
strokes of my own deeply personal, sexual, and transgendered self. My first analyst helped free
me from my chains by helping me speak of these unspeakable fantasies, not just of torture, but
of loving and sexual merger. I became human. I also came into my manhood, not just in my
mind, and not just as an analytic artifact or enactment. I found the toddler boy buried deep inside
who longed to sit in my analyst’s lap and be snuggled and kissed. I found the hesitant child
giggling for approval. I could hear the adult psychiatrist in me pleading in high pitch to my
patients to forgive my strangeness. I became emboldened by felt urges in my sexed and gendered
body, genital feelings and longings, in addition to a multitude of other gendered body feelings
that brought delight and glimpses of affective liberty. In retrospect, my first analyst’s early
attention to my pressing hard on the ottoman with my left foot had highlighted my conflict with
analytic body states of desire, longing, omnipotence, aggression, and excruciating discomfort in
the presence of another.
A combination of erotic transference; deep exploration of self-loathing; and mining of
gendered and nongendered memories, feelings, and body states set me on course to bodily
striving, something that had been damned up hysterically in my anxiety-ridden body. I was not
on male hormones yet, but at times felt like an adolescent male riddled with sexual preoccupa-
tions. I wondered if it would ever stop, and at the same time I longed for it to never end because
the body states of desire and arousal were increasingly satisfying. I was finding my sexual self,
exploring and activating it in fantasy, through my clarifying gender identity. But I also wanted
these states gone because they lived so much in fantasy. I did not have all the bodily masculine
qualities I imagined. So although my analytic experience of my body, desire, and anxiety was
fruitful and deeply freeing, it was also torturous in the way that it mocked the reality of my
female body.
Isn’t this what so many transgender people who choose transition must overcome? The
mocking that their own self and body does to their self and body? Others do it as well, as I
felt and experienced my analyst do at times when they could not mirror me in the intricate and
delicate way I so needed. But my own knowledge of my physical biological makeup and my
mental and gendered makeup, and how they clashed, kept me psychically chained and bound.
I surmise that it was impossible for my analyst at that time to formulate a broader interpreta-
tion that might have encompassed both the truth of my love difficulties and the truth of my body
and gender problems within the context of transition as partial solution. For my part, I could not
see that I was asking my analyst to do more than that analyst could fathom. I am convinced it
814 JACK PULA

was harmful for me to lose the continuity of my treatment at a time when it could have been so
transformative. Despite the subsequent period of bereavement that frequently had me longing to
be back with my first analyst, I have come to see that proceeding in that particular analysis was
impossible. In the process, I learned about the psychoanalytic phobia of action, and the relative
nature of enactment definitions and how those definitions govern what is permissible and
tolerable for the analyst (Aron, 2003). I also learned the harsh reality that an analytic dyad
can carry a certain potential or capacity that can be exhausted and, ultimately, counterproductive
to maintain (Levin, 2011).
This brings me to the controversial nature of transgender and gender transition, especially in
psychoanalysis, where anatomy has been considered destiny. Gender transition is an extreme
medical treatment that alters the body through hormones and surgery, and is medically necessary
for those who choose it. Gender is an essential feature of life that people live with and through,
although we lack full understanding of its development and purpose. I believe it partly serves the
purpose of connecting us to others, socially and erotically, while also protecting us, framing us in
a dramatic, stylistic manner that allows us nuanced access to and buffering from associated
feelings. Gender is not anatomy per se, but often relies on anatomy, builds on and from it, and is
concretized through it, for better or worse. Although often experienced vibrantly and joyfully,
the angst that gender evokes in trans and nontrans people, and the conflict it can spark within
and between people, speaks to the potentially violent currents it carries and wields. Gender can
be a violent experience both internally and externally. Gender transition usually brings peace and
relief as one settles into new life in the body that fits one’s mind and identity more completely,
but it can also be a violent experience. Gender transition may be fraught with potential problems
and anxieties; it is to be approached with care. I have experienced these anxieties about gender
transition as a transgender person and patient, and as a clinician working with transgender
people.
So, what is an analyst to do when a tomboy butch dyke lesbian patient converts to a
transgender male wanting gender transition in the context of analysis? The psychoanalytic
field’s pathologization of certain actions, in addition to excessively privileged rules about
abstinence, neutrality, and anonymity, may camouflage a negative countertransference and bias
against gender transition even in a well-meaning, caring, progressive analyst. This can lead to a
harmful amplification and repetition of deep gender trauma that breeds hopelessness and help-
lessness in the analysis. Optimally, psychoanalysts are able to open and hold a space and
relationship that delicately resurrects and articulates this trauma while nurturing new, healing
solutions, rather than old persecutions. This requires psychoanalysts to be comfortable with
gender transition as a potential solution, and to manage the complexity of patients seeking
gender transition, analyzing such transitions without interfering. After all, as Smaller would
argue, “’Analysis, whether child or adult, is always about taking some sort of ‘action’ . . . with
the aim of moving one’s self forward in development, relationships, learning, work, and life”
(Kenny, 2013, p. 797).

BECOMING MY OWN MAN

I consulted an endocrinologist on how I would become a man, should that be my choice. After
considering my decision for two years, I started leuprolide acetate injections, a gonadotropin-releasing
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 815

hormone agonist that suppressed gonadotropin secretion and put me into menopause. Leuprolide is
used in natal males and females to shut down the production of testosterone and estrogen in preparation
for cross-sex hormones, but is not FDA approved for transitioning. If an insurance company is
unwilling to pay for this indication, a transitioning patient can pay approximately $800 out-of-pocket
per injection, and may need two to five injections. Leuprolide from Canada is less expensive.
Leuprolide is clinically indicated for endometriosis, so female-to-male transmen with endometriosis
may be able to get this treatment covered by insurance. Although some people experience discomfort
from leuprolide, I only experienced mild hot flashes that winter, nothing worse than being in an
overheated New York apartment. Three months after starting leuprolide, I started intramuscular
testosterone (often referred to as T), which I self-inject weekly. I began at a very low dose, which
my endocrinologist slowly increased and modified with the goal of maintaining a testosterone blood
level close to 500 ng/dl, the mid-range of normal for adult males, and optimizing physical responses,
positive (facial hair growth) and negative (severe acne, elevated hematocrit). I chose to work with an
endocrinologist because I wanted someone who would titrate testosterone slowly, allowing my body
and mind time to adjust. I wanted to feel and experience the hormone’s effects as part of me, rather than
as if a foreign substance was overtaking me. It was also important to me to monitor my levels and know
my body’s response. The human endocrine system operates with exquisite biological finesse. I knew
that commandeering mine into a new organic milieu was a serious medical and scientific undertaking.
When I say that gender is violent, I mean that gender can have a forceful, concrete felt
impact on the body and mind, both in navigating relationships with others and in one’s
relationship to one’s own body, something many of us are unaware of. As I went through
gender-exploring therapy and gender transition, I became aware of the absurdity and genius of
gender, a realization that made choosing transition fraught with conflict and required me to
embrace the ingenuity and creativity of gender, rather than crumpling under its absurdity.
Transgender identity and the transition phenomenon can simultaneously unhinge and stabilize
the gender binary in a way that made me say, “This is absurd, but real; typically-gendered
people don’t experience the absurdity. I want the ingenuity and joy of it, euphoria not just
dysphoria.”
For me, using hormones has been a mixed experience. Testosterone has never led com-
pletely to the fat redistribution changes I want on my hips, buttocks, and thighs. It is likely that
my genetic and anatomic makeup will never permit that. So no matter how high the dose or
how long I am on testosterone, I could remain with the curviness that reveals the woman in my
body. I find this potentially the most disappointing part of my transition. It has led me to
continue to keep my weight lower than I want, to have the least noticeable female stigmata on
my lower body. On the positive side, the hair follicles in my face have sprung to life in
response to testosterone, and I have grown a goatee that is the secondary sex characteristic that
most helps me pass as a man in nearly all social interactions. Prior to the beard, people
frequently stumbled over my gender, calling me “Sir,” then apologizing and calling me
“Ma’am,” an embarrassing, disappointing, and at times threatening experience that I hated.
My voice has deepened, as testosterone has made my vocal chords thicker and shorter. But my
voice is not as deep as I would like and on the phone I often do not pass, unless I mindfully
lower my pitch and use my first and last name when I introduce myself, as my voice instructor
recommended.
During the first six months of hormones, I gained weight, both muscle and fat. I drank protein
shakes, lifted light weights, swam, and did push-ups and other strengthening exercises. My
816 JACK PULA

biceps popped. I was happy with bigger muscles and more weight, but unhappy that my seat had
grown heavier and was still taking a woman’s shape. Over the next six months, I lost weight and
continued to struggle with aspects of my body that remained feminine. I started confronting the
reality that parts of my biology are not changeable, including some secondary sex character-
istics. During several years of therapy and analysis, I had repeatedly prepared myself for this
possibility, but it was different facing the concrete disappointments of gender transition.
Despite my issues with my curves, people meeting me for the first time easily saw me as a man. I
felt both satisfaction and annoyance; satisfaction in having enlivened and actualized my male self
effectively and annoyance because I partly wanted recognition of the frustrating complexity of my
body. Although I was hiding that aspect of myself from others, I was also processing, appreciating,
resenting, and mourning it in varying degrees. I wondered, “How is it they don’t see? They are just
not looking.” Knowing that if someone looked, they would see my biology and my history, made
me scared at times, angry at times, and joyous at times about the way my body and gender identity
inherently betrayed the binary classifications of gender. That joy is often celebrated by genderqueer
people who choose not to transition. For me, it is uncomfortable joy. I want it gone, but if it is going
to be there I will take it. Which translates to: “If I can change this body to be a man, I will! But if my
biology resists that, I will also live with the hybrid on the outside, as on the inside, and I will find
joy in it.” Both positions rally my defiant determination to not just survive, but thrive. This also
reveals the bind I was in for many years, before I could know and prioritize my desires to make
commitments to identity and decisions on how to live.
Eighteen months after starting hormones, I had a double mastectomy as part of gender-
confirming surgery. My chest healed well and quickly, though I lost weight and battled a back
injury and pain that prevented me from exercising like many transitioning transmen do to
maximize change potential. Testosterone sometimes causes discomfort in my leg muscles. I
can feel restless after sitting with a patient for ten minutes, and need to stretch between
appointments, as if to grow my muscles to meet the demands of testosterone. I often wonder
how, if not for the back injury, I might convert this stimulation into something physically
productive and strengthen my body. Over time, I returned to strengthening with the help of a
physical therapist. I have returned to my pool to swim with my new bare, male chest. When I
swam there prior to surgery I appeared as a bearded “woman” with a man’s name. Now I am a
scarred, bearded man with womanly curves. I searched for and found optimal men’s swim trunks
that are big enough to hide those curves, but snug enough to allow me to swim laps unhindered
—a coup in the latest version of my gendered wardrobe conundrums. I hope that healing and my
biological response to testosterone will allow me to develop a strong, masculine body. I am more
content with the possibility that limitations will remain. I may not be able to swim or lift weights
quite the way I want, or be active in the way I imagined. How my unique biology—my aging
body with its medical problems, non-modifiable anatomy, and genetically determined fat cells—
will ultimately collaborate with my transition is unclear.

CLINICAL COMING OUT: VOLUNTARY VERSUS INVOLUNTARY DISCLOSURE OF

GENDER IDENTITY AND ITS CLINICAL IMPACT

It was the last session of a consultation with a young transgender woman, who came to me for a
second letter to support her readiness for gender-confirming surgery. We had quickly delved into
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 817

emotional territory concerning relationships, family, and sexuality—issues important to consider

when preparing for such a major, irreversible life and body change. She told me she appreciated
the opportunity to explore more deeply, but she was ready to end the consultation. At that last
session, I was stunned when she told me how my disclosure in an earlier session of my own
transgender status had truly surprised her. I had assumed that her primary therapist had told her I
was a transgender psychiatrist. When I had spoken openly about my own experience getting my
name and gender changed on my social security card, in response to her story about barriers she
had faced in changing her name and gender marker, I did not know I was making such a
disclosure. At that last session, when she told me she could not believe I was transgender, I
found myself sitting in disbelief that she convincingly found me a cis-gendered male.
Although today I pass as male with relative ease, I remain aware of the impossibility of
predicting others’ gendered perceptions of me. When I started coming out in the psychiatric and
psychoanalytic professional communities as transgender, I was a gay-identified butch woman. I
assumed that my patients knew I was gay, based on my appearance. With the cultural recogni-
tion of trans and the accompanying focus on the phenomenon of gender transition, the far
broader array of possible sexual and gender identities revealed the parochialism in my previous
assumptions.
Over the course of approximately eight months, I came out at my hospital job, at my
psychoanalytic institute, to approximately thirty patients in my private practice, and to family
and friends. Doing psychoanalytic work as someone in transition is unique. I see a variety of
patients, most in psychodynamic psychotherapy, and as a psychoanalyst-in-training, I also
see patients in psychoanalysis. We had the opportunity to directly discuss my transition after I
came out to them and explained some of the transition process.
My decision to come out and transition while in practice is a definitive, no-holds-barred
actualization of my own agency. As someone who shrank from my identity for years, I had
become comfortable in the role of therapist where the focus was on the patient, and in my own
mind I could hide behind ambiguity. Coming out was like marking my territory, allowing myself
to smell and be present with the patient in the room in a way that could allow them to link with
me as a person. Some may say this is irrelevant and that a patient’s fantasy of me and
transference toward me are most important. I have wondered if a gender-ambiguous therapist
has an advantage with patients because broader and multiple transferences may be stimulated
more easily. Now that I am in the position of feeling both genderqueer and transgender mascu-
line, my experience of myself in relation with others has shifted because of new elements of my
body and resolving conflicts in my mind. How this comes into play with patients is an ongoing
question. The most marked physical differences are my beard, my voice, and my chest; these
characteristics influence my self-image, my self-esteem, how I carry myself, and how others
perceive me. I come out feeling very different, yet the same, which adds new layers of
complexity to how patients experience me, how I experience them and us, and how I read
and interpret our dynamics.
When I first came out, a long-term patient of mine with a history of trauma perpetrated by a
male shared both admiration and concern with me. The patient expressed gratitude for my
sharing my transition plan, but also concern that my deepening voice and manly manners would
make me too rough, hence likely to evoke painful memories of the early traumatic relationship.
Instead, the patient has shared deeper aspects of early life, with an enhanced ability to observe
and reflect. The patient has been able to discuss choosing child-like positions that result in
818 JACK PULA

victimization and masochistically imprison the patient in the tortured way the patient has come
to expect. At the same time, the patient has revealed an ongoing desire to keep me in the female
gender, often letting me know of conversations with others in which I am described with female
pronouns. Discussions of this have revealed the patient’s shame over their own limits to
embracing my transition, and how that centers on a need to maintain some semblance of a
good female object, which was partly found in a beloved grandmother and also torn asunder by
maternal betrayal. As I move deeper into transition, and the therapeutic relationship deepens, I
wonder how the patient will experience me and my gender, both differently and the same, and
how that will promote the ebb and flow of progress and regress. I wonder if this patient will
experience me more fully in my maleness and how that will run parallel with or impact progress
in developing fuller object relatedness with men. I wonder if the patient will continue to use
gender rigidly to protect against old but very present traumas that live on in their relational life.
My voice has become a focus for me, as I have experienced the way its drop in pitch has
empowered me as a man, but constricted a crucial domain of affective communication that I
used with patients. I sense irritation in others due to perceived harshness in my voice that was
not there previously, or that was hidden in a higher pitch. Making an interpretation that painfully
confronts resistance is now vocally more challenging than it would have been two years ago. I
find myself frying my voice in an effort to soften it, because I cannot actually soften it without
feminizing it. This not only reveals to me my own defensive use of my voice, but also
demonstrates a biological–psychological gendered voice-trait phenomenon that links voice,
affect, therapeutic alliance, and transference in a gender-specific way. I am most aware of this
during treatments where the patient moves from a face-to-face position to lying on the couch, in
which voice then becomes the link between the patient and me. When the patient experiences
my voice as male, female, or trans, or some mix, this simultaneously promises and threatens to
expand and constrict the treatment. Such openings and closings, which occur in all treatments,
occur here with a particular slant that I must navigate with my full self, both in the room and
removed, hovering, waiting, wondering how shifts are related to me or the patient, just as one
would in any treatment, but in this case done from a unique trans position.
Another long-term patient I treat psychodynamically was traumatized by men. The transfer-
ence was positive, even through my transition. Recently we had a conflict over the treatment
frame, during which a negative transference arose. The patient said something had changed, and
was not certain if it was related to my gender transition or their own transferential issues. Could I
be acting in a harsher manner as a result of my transition? My experience of the patient felt no
different for me as a male therapist than as a female therapist, and I felt my handling of the
situation was consistent with how I would have handled it pretransition. Aware of my vocal shift
as a man, I was concerned that my changed voice had taken on an irritable quality. I asked
people close to me if this was so, and was told no; but I still wonder. My patient and I have yet
to understand the role my male voice and gender transition played in their distrust and anger. Did
my voice serve as template on which this negative transference arose more easily? Had I
unwittingly evoked this response? This was my first instance of experiencing, observing, and
discussing this patient’s negative transference in treatment, and I believe the change in my voice
opened a potential space for this patient to experience disturbing affects with me and about me.
My first personal analysis included a vibrant erotic transference that partly led to my self-
realization as a transgender person. Prior to my transition, I was unable to see myself as a fully
sexual person. As an analyst-in-training, I have explored my anxiety that my patients might
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 819

develop erotic transferences toward me, and learned about my own blind spot about this, a
genuine difficulty for a psychoanalyst who hopes to be open to navigating erotic transferences in
a way that will optimize healing. When I previously mentioned being present in the room in a
way that allows my patient to smell me, I was including this type of presence. My own presence
with as much affect, desire, and potential as a patient can resonate with allows me to respond to
my patient’s experience of the whole me. Analysts don’t often write or speak about treatments in
which their patients’ erotic transferences are worked through, and even more rarely write about
their own erotic inhibitions that may inhibit or derail a treatment. My experience as nonsexual,
then sexual, object, associated with a crossing-over into a new realm of inhabiting my body has
opened up an avenue for me to more fully hear and experience patients. Not surprisingly, this
has opened up a space for patients to express their own sexuality. My patients, especially my
male patients, have shared more sexual material since my transition as I have become more open
and less anxious with patients. I am less likely to avoid uncomfortable affects, be they mine, the
patient’s, or shared; and less likely to defensively interpret something as coming from the
patient.
Some of this change emerged from leaving one analyst for another and experiencing
different styles of analysis and supervision. Some change emerged through the full embodi-
ment inherent in my transition. And some resulted from my having weathered the experience
of my personal disclosure to my patients. It brought me foursquare into the room. Although I
am the same person I was pretransition, I am also drastically different. My willingness and
ability to bring my self onto the therapeutic stage while keeping the patient at the forefront is
radically new.

GENDER AND SEXUALITY

Many people claim that gender and sexuality are distinct entities that are too often confounded.
Although I appreciate the need to distinguish the two and resent the lazy confounding of both, I
disagree that they are so distinctly separate. I wonder if people who say this are trying very hard
to uphold the full human dignity of transgender people by making certain we are not equated
with sexual perversion, as we historically have been. It is laudable and important to appreciate
the full meaning of gender outside sexuality. But in my experience, through a painful and
liberating analysis, and in transition, my sexuality has come fully into play as part of my gender
identity. I feel blessed by the way my appraisal of my sexual and gendered life, and my ability to
bring those together in a gratifying manner, informs me of something beautifully human.
Embracing the sexual nature of my gender has allowed me to embrace my identity as transgen-
der and pursue transition, rather than crumble under the absurdity of gender when I denied its
sexual power.
I have said that gender is violent, and that it is both a form of absurdity and ingenuity. To free
myself from the violent shackles of gender, I had to come to terms with the way I experienced it
as both absurd and ingenious. I confronted my own need to shackle myself by viewing gender
harshly, in myself and others, as absurd. I had been beating myself up for having a gender at all,
and partly wishing to annihilate the concept, because it was absurd to me that this powerful
phenomenon could cause me so much pain, and could have such profound impact on others and
how they treated me.
820 JACK PULA

But I desperately wanted my gender, to live in and through it successfully. Gender is a

creative, ingenious vehicle for relation, communication, affect, merger, boundary, sharing,
bonding, entering, and leaving. It forms and articulates sexual calling. This seems evident
from my own experiences, and from observing the culture and listening to patients, trans and
cis-, strive, thrive, and stumble over perceived success and failure of gender embodiment. This
does not mean that I believe oversexualized gender should go unexamined. The oversexualiza-
tion of male, female, and other forms of gender expression causes harm to countless cis-, trans,
and genderqueer people, young and old. However, the journey of discovery and embodiment of
one’s physical and sexual self that so many humans make through their gender, with relative
success and joy, is testament to the profound power and pleasure gender enlivens in millions of
people.
I wanted to be one of those millions finding power and pleasure in my gender. First, I
envisioned my self, my sexuality, and my gender as complementary. Then, believing that
transition would free me up for finer tuning, I embarked on a medical and social transition. I
began to breach the limits of my body to make me into a man. I envisioned a lean, flat-chested
me, with dissolving curves, deepening voice, and modest but confident muscles in my chest,
arms, and legs. I had a strong upper body and was confident it would respond well to hormones.
My lower body was a source of ongoing dysphoria that led me to shift my weight in efforts to
optimally masculinize my body. I knew I was seeking to overcome lifelong body limits. What
would my biology allow? This is a terrifying question. A patient put it well when he said, “For
years I have held on to the potential for gender transition; to do it seems too scary because if it
does not go as I have imagined, I will no longer have the fantasy and the hope to hold onto.”
Finding pleasure in my gendered body has encompassed many aspects of my mental,
physical, emotional, and relational life. Sexuality is a private and shared domain that pulls in
and through these nuanced human experiences in nonlinear, conscious, and unconscious ways.
How a gender transition shifts the quality of one’s sexuality is a topic for further exploration, but
I am certain it lends itself to profound discovery about gender and sexuality, especially through
formal psychoanalysis and psychoanalytic treatments. I can say without a doubt that my gender
transition continues to open up aspects of my sexuality that have been problematic or even
closed off for me, and this has moved me into a far healthier and more loving relationship with
myself and my body. For other transgender people, the opening up of bodily and sexual
meanings, and potential reworking of multiple traumas, which may be inherently altered through
bodily transition, offers a rich, ongoing process of discovery and change, which psychoanalytic
treatments are most optimal to hold and progress.

CONCLUSION

In considering whether or not to publish this personally revealing article while I am an analyst-in-
training, I wrestled with my own discomfort over printed self-revelation, and my felt vulnerability,
including my fears that some analysts might consider both my trans identity and my self-disclosure
as indicators of psychopathology. Many analysts around the globe consider transgender people, a
priori, psychotic. As I reflect on some of the bias and discrimination I faced and overcame in my
own training, I am struck by the reality that our field of study and treatment—a field of care and
knowledge—is globally blind to the harm it does to gender-atypical people, not only in treatments,
 UNDERSTANDING GENDER THROUGH TRANSGENDER EXPERIENCE 821

but in theory and in the stereotypes it perpetuates in the culture at large through ongoing
assumptions about normative gender and sexuality.
Just after coming out as trans when I was an early trainee, I was told by a senior analyst that I
had the choice of either taking up a political platform or truly studying and learning the field of
psychoanalysis. That analyst seemed blind to the way psychoanalysis is culturally bound and
inherently political, especially when it propagates theories about gender and sexuality. I was
angry and disappointed, but realized that whatever the reason the analyst constructed this false
choice, it was neither my task nor desire to battle the people I wanted and needed to learn from. I
recognized that by living, being, learning, treating, and teaching within the field of psycho-
analysis, I might help candidate colleagues, mentors, and faculty members across institutes to
learn about transgender people and how our inner and outer realities are interesting and
important in their own right. Our experience can also creatively inform a wider understanding
of gender and sexuality in ways analysts historically could not imagine. It is my hope that these
reflections will help open up that understanding to include the voices and ideas of transgender
people.
The ongoing destructive notion that transgender people are inherently abnormal, perverse,
and psychotic is an epistemological problem that warrants scrutiny and correction in the field of
psychoanalysis. It will take time, thoughtful discussion, and sharing of ideas, hopefully with the
inclusion of transgender writers and analysts. Religion, psychoanalysis, psychology, and psy-
chiatry play powerful roles in how transgender, gay, lesbian, and bisexual people are viewed and
treated around the world. I resist the notion that psychoanalysts cannot be political, intellectual,
scientific, and caring at the same time.
Last, I hope that my reflections communicate my own imperative to foster psychoanalytic
respect for transgender patients in our human totality rather than reducing our experience to
something predictable. There are at least as many transgender subjectivities as there are
transgender people. My experiences may describe something many of us hold in common, but
I do not represent or understand all transgender experience. The ongoing difficulty that the
psychoanalytic profession has in opening up to non-pathological views of transgender people
must be addressed. At the same time, there must be a preservation of analytic space to take up
the personal struggles an individual transgender person may bring into treatment. The unique
frame and techniques make psychoanalytic treatments optimal for transgender people seeking a
full understanding of their selves in a way that allows them deep contact with forms and states of
wellness and illness and everything in between. As a group, transgender people face significant
mental health challenges, including high rates of depression, anxiety, alcohol and drug abuse,
suicide, and suicide attempts, even after transition. For any individual transgender person, the
opportunity to explore mind and body, and external and internal life, is life-promoting, even
lifesaving. It is my goal to promote the expansion and availability of these opportunities, in the
context of radically new approaches and safe milieus, free of ideology privileging constructs
determined to keep transgender people in a pathologized position.

ACKNOWLEDGMENTS

I thank Susan McNamara for inviting me to contribute to this issue. In addition, I thank the
Committee on Gender and Sexuality of the American Psychoanalytic Association, which invited
822 JACK PULA

me to become a member, and to speak at a forum with another transgender colleague at the
January meeting in 2012, when I was first coming out. The support of the committee was
integral in giving me the courage to proceed with psychoanalytic training. I thank my parents,
Edward Pula and Barbara Baldwin Pula. I also want to thank the scores of gay men and women
psychoanalysts who bore the brunt of homophobia and transphobia, and paved the way for queer
analysts to train at psychoanalytic institutes. Specifically, I thank the following people and
groups for emotional and academic collegial support: Stewart Adelson, Carlos Almeida, Reza
Amighi, Kenn Ashley, Elizabeth Auchincloss, Mary Barber, Robert Berman, Brett Blatter,
Walter Bockting, Stanley Bone, Juliet Vacirca Brown, Lucas Bulamah, Ken Corbett, Diana
Dragatsi, Jack Drescher, Anke Ehrhardt, Marc Epstein, Evan Eyler, Michael Feldman, Marianne
Goldberger, Ethan Grumbach, Kelli Harding. Wylie Hembree, Dan Karasic, S.J Langer, Burt
Lerner, Jeffrey Lieberman, Oren Messeri, Wendy Olesker, Mark Petrini, Justin Richardson, Avgi
Saketopoulou, Susan Vaughan, Agnieszka Wisniewski, Rick Zimmer; members of the Group for
the Advancement of Psychiatry Committee on LGBT Issues; the Association of Gay and
Lesbian Psychiatrists, especially its transgender committee; all colleagues and psychiatric
residents at the Columbia University Comprehensive Psychiatric Emergency Program (CPEP);
and the World Professional Association for Transgender Health (WPATH).

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