“If I hadn’t transitioned, I’d be dead, I would have committed suicide.” As a psychoanalyst, I often hear this from analysands who identify as transgender. When someone makes such a dramatic confession, what is at stake more than gender fluidity it is finding a new way of being. To cross the frontier between genders is often experienced as traversing a mortal threshold, a passage from an impending doom to a possible renaissance. My clinical practice has taught me that quite often, the predicament of analysands identifying as transgender hinges around existential issues: beyond what has been called “gender trouble,” one often finds issues of life and death.

In 2010, feeling the need to reflect upon the lessons I learned from my practice, I wrote a book about patients who identified as transgender entitled Please Select Your Gender: From the Invention of Hysteria to the Democratizing of Transgenderism. This book summarized my experience during a time of reform that consolidated what I call a “democratizing” of gender-nonconformity, a progressive visibility of non-normative forms of embodiment that was fueled in great part by the accelerated popularization and increasing mediatic presence of the trans experience across all levels of popular culture in the United States. This evolution, rightly described as meteoric, has made the word “trans” an everyday term. Another sign that the transgender experience has permeated current public discourse is that more and more often we use the term “cisgender” to refer to those whose gender matches the one assigned at birth. While the word has been around for two decades, the adoption of “cisgender” in common parlance is important in many ways. Cisgender, obviously the alternative to “transgender,” questions the notion of normality in sexuality and sexual identity by inserting a new parallelism. This is also a movement towards the depathologization of gender variance and sexual non-conformity. One of the consequences of using “cisgender” is to wonder about the alleged universality of heterosexuality. How has heterosexuality become the status quo? If not too long ago, homosexuality was considered an aberration, a deviation, there periods as in Athens in the fifth century BC when it was fully accepted. Until recently, nobody talked about “heterosexuals” because all assumed that heterosexuality was the norm. Of course, this type of terminology is ideologically loaded, and conveys culturally constructed ideas of norm and deviance. As Jonathan Ned Katz has shown in The Invention of Heterosexuality, until 1923 the term “heterosexuality” referred to a “morbid sexual passion.” The current usage derives from a term meant to legitimate men and women having sex for pleasure, which reveals how norms are constructed, are often are not far from transgression.

Freud always questioned the idea of normalcy in human sexuality. He observed that sexuality rather than “straight” is “skewed” or “queer” — it has no specific object (besides satisfaction), it operates in capricious ways, and is dominated by the drive, a border concept between flesh and language. Deviance is the norm. Similarly, the term cisgender highlights that for both trans and non-trans people the assumption of gender is not a linear process and that like heterosexuality, cisgenderism is historically and culturally determined. It therefore should not be taken for granted as the standard of normality or as a natural destiny

Despite a resurgence of conservative opinions in recent years, the trans experience is challenging de facto traditional ways of looking at gender and identity in general. Transgender people, along with other gender dissidents, are proposing new ways of inhabiting our bodies. While we see notions of identity shift, our conceptions of how gender is related to the body are being challenged and updated. This social change is reflected in the material we hear in the clinical practice and will shape the way psychoanalysis is practiced.

In the 1990s, in the quiet solitude of my psychoanalytic office in Philadelphia, I would not have imagined for a moment that I would have had to revise my ideas about gender and immerse myself in the deep waters of identity politics. But one day, I heard something unusual in what some of my patients were saying. Quite a number would ask questions such as: “Am I straight, or am I bisexual?” I first thought that these were questions about sexual orientation based on what type of sexual partner they preferred, that they were wondering whether or not they were heterosexual. But soon I became aware that they were asking something that went along the lines of gender identity, and meant in fact: “Am I a man or a woman?” or “What is a woman?” as a way to pose a more general question about themselves, “Who am I?” This led me to relate their uncertainty to the more general problem of many trans people for whom it can be said that this question is taken as an answer: they know who they are, a woman, a man, or something else altogether, and they go through changes (social presentation, gender roles, legal documents, bodies) to better reflect their identity. They search for a more livable embodiment. Their self-awareness is expressed in statements such as those I heard from one analysand: “I have the worst birth defect a woman can have: I was born with a penis and a pair of testicles ” or another one who told me, “I was declared girl at birth but my true self is masculine. I felt uncomfortable in my body, being female never felt right.”

When someone realigns an inner sense of sexual identity with the flesh they inhabit, the possibility of embodying a different gender from the one assigned at birth implies that the materiality of the body is not immediately given. The expression to have a body shows that one is not a body. We do not have an unmediated, natural relationship to our corporeal being. Furthermore, the body is not a fixed entity but requires a process of embodiment, the body is a becoming. The body is not just a collection of organs but a place where culture, society and flesh meet. In fact, this process in always a work in progress, and therefore one is never fully in control of one’s body. Otherwise, why would we be seduced by slogans such as “get your body back.” Where do bodies “go” that we need to “get them back”? Why are we constantly trying to tame our bodies with diets or exercise? My argument here is simple: those analysands who question their assigned gender reveal a disjunction between the subjective experience of the body and its material reality. But this is not an exceptional experience. In fact the trans experience makes explicit a process of embodiment that is universal — the challenges of assuming a body that is sexed and mortal. For both cis and trans people, it is sexual difference that appears as a conundrum.

When I published Please Select Your Gender, I did not expect then that I would end up riding a gender-bending media wave that has swept everything in the American imaginary and in pop culture; this tsunami also engulfed most psychiatric and psychoanalytic practices; psychoanalysts started questioning the classical approaches to gender and sexuality That is why my most recent book, Transgender Psychoanalysis: A Lacanian Perspective on Sexual Difference, aims to evaluate gains and losses, look at new trends, and forge original concepts that are needed to make sense of what has happened in such a short time. Despite the growing media presence of transgender people, particularly in the United States, the transgender community continues to be an under-researched population, regardless of the discipline that frames the work. This situation is even more pronounced in the field of psychoanalysis.

The most visible versions of the transgender experience in America, if we judge by the media representations available, often contradict what I hear in the clinical practice with analysands who identify as trans. Often gender transition is presented publicly as a consumerist choice, a life-style preference comparable to moving to the suburbs, giving up smoking, or becoming vegetarian. As Jennifer Finney Boylan’s (2003) suggests, this is precisely what the trans experience is not: “What it’s emphatically not is a ‘lifestyle,’ anymore than being male or female is a lifestyle. […] Being female is not something you do because you are clever or postmodern, or because you’re a deluded, deranged narcissist.” (p. 22). Furthermore, Jay Prosser observes that being trans can be an endeavor that could take over people’s lives: “As the insider joke goes, transitioning is what transsexuals do(our occupation, as consuming as a career)” (p. 4; italics in original).

Nowadays, the trans body has become a social barometer of the politics of sexual difference. Given the gradual but increasing erasure of the traditional markers of sexual difference in today’s society, we can note a general movement toward greater fluidity of gender. Psychoanalysis offers a powerful critique of hetero-patriarchal and heterosexist forms of cultural and ideological domination. Despite the fact that queer theorists such as Tim Dean, Chris Lane, Lee Edelman and Lauren Berlant, among others, have found that Freud’s drive theory debunks the binary of heteronormativity and the illusion of normalcy in sexuality, for years classical psychoanalysis has pathologized non-normative expressions of gender and sexuality. Based on reductive distorsions and biased interpretations, transgender experiences have been pathologized (the generalized assumption has been that most “transsexuals” are psychotic). For several years, I have been arguing for a depathologization of trans expressions. Many critics have shown that there are more grounds for critical collaboration than opposition between the trans and the psychoanalytic discourses. I strongly believe that the trans experience can reorient psychoanalytic practice, as many contributions of Sigmund Freud and Jacques Lacan hold great potential for a non-normative understanding of gender, particularly as it pertains to the lives of trans people. Psychoanalysis needs a major realignment, and the time is now.

For decades, feminists have looked at psychoanalysis with great suspicion, objecting to patriarchal notions such as “penis envy.” If Lacan does not fully dismiss Freud’s “phallocentrism,” he makes a radical political intervention. His theory of sexuality redefines the controversial phallus not as something made of flesh but as signifier, a symbolic instrument introducing difference. The phallus is not just simply the penis, a bodily organ, as it was for Freud, which clarifies the distinction between sexuality, anatomical sex, and symbolically constructed gender. Lacan provides us with a new term sexuation, which unfixes notions of sexual identity as either sex (the biological substratum) or gender (socially constructed). For psychoanalysis sexual difference is neither sex nor gender, as neither term captures the radical negativity at stake in sexual difference. This is an impossibility that, like death, all subjects need to confront by making a forced choice. Recently, Alenka Zupančič (2017) has proposed that there is a fundamental negativity, a disruptive instability, at work in sexuality, a deadlock that is the philosophical problem of psychoanalysis.

In the unconscious there is no representation or symbol of the opposition masculine-feminine. Sexual identity is always precarious because the human infant becomes sexed without fully symbolizing (unconsciously) a normal, finished sexual positioning. Psychoanalysis attempts to clarify how not only sexuality fails to conform to the social norms that regulate it but also how the various fantasies are constructed to veil the structural failure.

What sets Lacanian psychoanalysis apart from other discourses about sexuality is that it brings to the fore the structural impasse inherent in sexuality. Lacan expanded on the paradoxes already observed by Freud, who noted that while there are admittedly two sexes, there is no concept to account for this assumption. The perplexing fact, Freud wrote, is that “when you meet a human being, the first distinction you make is ‘male’ or ‘female’? and you are accustomed to make the distinction with unhesitating certainty.” Yet, he writes, one “cannot give the concepts of ‘masculine’ and ‘feminine’ any new connotation. This distinction is not a psychological one.” Even when we may deny the gender divide altogether, it is clear that our most fundamental means for perceiving and classifying one another upon running into a stranger are based on making a logical jump. Between genders all we have is an incommensurable difference. Rather than bridging this gap, Lacan stepped into this gap with his dictum that “there is no such thing as a sexual relation.”

Being a man, a woman, or anything else altogether is one of the many possibilities of misfire. In sexual matters of identity or object-choice, everyone fails. Lacan’s formula “There is not such a thing as a sexual relation” does not mean that people do not engage in sex, or fall in love, or assume more or a less precariously a sexual identity, but rather than there is something constitutively out-of-synch and inherently incommensurable, even incompatible, in human sexuality. Between cis men and trans women, between trans men and cis women, between trans men and trans men, between trans men and trans women, between trans women and trans women, between cis women and cis women, between cis men and cis men, between cis men and cis women, there is nothing but difference. All combinations are possible but there is no symmetry. The problem that one finds in the clinical practice is always of the order this unassimilable aspect of sexuality. “Sexual difference” may exceed the notion of sexuality since it has to do with issues of embodiment — the challenges of living in a body that is sexed and mortal.

This is why, guided by my ongoing clinical work with psychoanalytic patients who identify as trans,I argue that those who undergo gender transition often do so because they are grappling with questions of life and death. If analysts could take the presence of death inscribed in sexuality seriously, and thus rethink their practice, they would engage in a practice guided by an ethics of sexual difference that I sum up in what I call “transgender psychoanalysis.” This trend was perhaps anticipated by Lacan, who once called up the figure of Tiresias, the mythical man-woman who was also a seer, as a role model for all psychoanalysts, a special protector or guardian of psychoanalysis — a patron saint.

The legend formalized by Ovid has it that Tiresias became a prophet only after having changed genders twice. The god Jupiter famously inquired of Tiresias who derives more pleasure from sex, men or women. Having lived in both genders, Tiresias was able to reveal to the gods the ultimate secret: he reckoned that women enjoy sex nine times more than men. Spited because she had argued that men enjoyed themselves more than women, the goddess Juno punished Tiresias’ indiscretion by blinding him. As compensation, Jupiter gave him the gift of prophecy. What Lacan discovered in Tiresias was less so a model of denaturalized sexuality, and more the awareness that it is not anatomy but sexual enjoyment that is crucial, an explosive mix of pain and pleasure that Lacan called jouissance.

When confronted with sexual difference or sexuation, one needs to take sides. There is a “male side” that is linked to phallic enjoyment and a “female side” whose form of enjoyment is not fully subjected to the phallus. These two positions are not determined by biology but by the logic of unconscious investments, to the point that, for instance, a cis male can nevertheless inscribe himself on the female side. Freed from the shackles of anatomy, the assumption of a gendered positioning has to do with self-authorization in speech. Here, the idea is that the authorization of a subject as a sexual being (man, woman, or anything else) originates in oneself; that is, in matters of sexual difference, one proceeds from one’s own authorization. Thus, sexual positioning is an area of ambiguity between author (a composer of a work) and authority (having power or control), interrogating both the function of an author and of authority. The phrase is a variant of Lacan’s better-known aphorism: “the analyst authorizes himself/herself.”[1] These are forced choices not dependent on the big Other (moral duty, law, institutional or social customs, and the like). To authorize oneself as a man, woman, or something else altogether, involves an ethical decision, as also happens when pondering the position an analyst should adopt. Here psychoanalytic ethics meets a new ethics of sexual difference.

The choice of Tiresias as the patron saint of psychoanalysis tells us in no uncertain terms that psychoanalysis needs to learn more from the trans experience, and that this is the only way to progress toward a future marked by all sorts of gender and body dissidence. We may remember that it was Tiresias who advised Oedipus after the latter discovered that something was amiss in Thebes. Freud also took on features of Tiresias. While fighting cancer in his jaw, Freud underwent a “Steinach operation,” which in medical jargon is also referred to as “castration,” for it is a simple vasoligation that he hoped would help with his illness, increase energy, and make him feel young again. Steinach’s cross-gender gonadal implants and his “rejuvenation” surgeries (or “reactivation,” as Steinach preferred to call them) were based on speculations about the aging process and endocrinal sexual functions; here was the beginning of all later gender reassignment medical practices. During the 1920s, the “Steinach operation” with its promise of eternal youth became extremely popular, and thousands of them were performed around the world. Freud proved in his very flesh that psychoanalysis had to push the sexual issue beyond the Darwinian concept of instincts and evolution; it would be forced to move in the direction of the death drive, in the hope of progressing even further, beyond death itself.

Tiresias, too, travels beyond death. In Homer’s Odyssey, when Odysseus summons him, Tiresias is already dead and lives among the shades of the

underworld. In order to summon him, he is offered ritual blood so that once revived, he can tell Odysseus how to go home. Tiresias incarnates a truth that is beyond life and death. If it sounds strange today, in our disenchanted world, to speak of offering blood to ghosts, this metaphor conveys that we, psychoanalysts, need to make such ancient allegories come alive by offering some of our living substance. If this allows us to go beyond the normative ideologies of gender and sexuality and the fear of trespassing on the limits of life and death, then the journey will have been worthwhile.[2]

Patricia Gherovici, Ph.D. is a psychoanalyst and analytic supervisor, founding member of Das Unbehagen, honorary member of IPTAR,  associate faculty at the Psychoanalytic Studies Minor, University of Pennsylvania and founding member and director of the Philadelphia Lacan Group. 

[1] As Bruce Fink (1991) proposes: “ ‘ l’analyste ne s’authorise que de lui-même’ (an analyst’s only authorization comes from himself, an analyst is authorized only by himself, or the only authorization one has to be an analyst comes from oneself), can be rendered as ‘One’s only authorization as a sexed being [male or female] comes from oneself’” (p. 83).

[2] Some fragments of this text are revised versions of sections from Transgender Psychoanalysis (Gherovici, P. 2017) and “Commentary on Gulati and Pauley” Journal of the American Psychoanalytic Association Volume: 67 issue: 1, page(s): 123-132 (Gherovici, P. 2019).


Fink, B. (1991). “There’s no such thing as a sexual relationship”: Existence and the formulas of sexuation. Newsletter of the Freudian Field 5:59–85.

Finney Boylan, J. (2003). She’s not there: A life in two genders. New York: Broadway Books.

Freud, S. (1933). New introductory lectures on psycho-analysis: Lecture 34. Femininity. Standard Edition 22: 112–135.

Gherovici, P. (2010) Please select your gender: From the invention of hysteria to the democratizing of transgenderism. New York: Routledge.

Gherovici, P. (2017) Transgender psychoanalysis: A Lacanian perspective on sexual difference. New York: Routledge.

Katz, J. (2007) The Invention of Heterosexuality. Chicago: Chicago University Press.

Prosser, J. (1998).Second skins: The body narratives of transsexuality. New York: Columbia University Press.

Shepherdson, C. (2000). Vital signs: Nature, culture, psychoanalysis. New York: Routledge.

Zupančič, A. (2017) What is sex? Massachusetts: MIT Press.