“The physical transformation does not exist”. Theoretical aspects and therapeutic implications.


Camilla is 14 years old, she goes to the psychotherapy support school service for anxiety problems. When she introduces herself, she says that she wants to be calledJohn, because she is convinced of being male, even if in a female body.What should we do? How to react? Should we accept or refuse the request to becalled in a way that does not coincide with the anagraphic identity?The list of questions could be very long in this regard.There are now numerous requests and situations of this type, in which young people criticize the so-called binary gender, claiming to belong to the opposite sex of the biological one, or to neither sex, or to both a little. Currently this is a much-discussedissue among teenagers, who can take mixed positions between wanting to change their sex or simply claiming a different name, clothing or sex life.The reactions of different families vary from supporting the path of sex change, to”friendly” acceptance with the willingness to use a name of the opposite sex, up to absolute opposition.The introduction will briefly mention epidemiological data on the prevalence and incidence of sexual identity problems both in the general population and specifically in adolescents1.

In this context, there are also interesting data on the frequency of transgender hormonal and / or surgical therapies2.

In light of the Human Birth Theory3, we argue that from a medical-psychiatric point of view, physical transformation does not exist4.
Where the previously mentioned therapies are a therapeutic remedy for endocrine diseases and therefore of the body, it is not correct to use the term transformation.

The concept that the word “transformation” finds its legitimate place exclusively in reference to mental phenomena was explained by Massimo Fagioli in the introduction to the book “Bambino, donna e trasformazione dell’uomo” (Child, woman and man’s transformation), known as ” Se avessi disegnato una donna”5(“If I had drawn a woman”), written in January 1996. Here, in fact, we read: <<Physical transformation is not in relationship with reality, it is a denial of reality in which physical transformation is impossible. The relationship with reality is given by the original idea of transformation for which psychic transformation is possible; the relationship with reality is given, it seems paradoxical, by the unconscious, by the unconscious fantasy that knows psychic transformation >>6.

In this premise, Fagioli analyzes the brilliant writing of Franz Kafka, “TheMetamorphosis” (Die Verwandlung in original German language)7, in which the

monstrous transformation of a non-existent Gregorio Samsa is described.Fagioli gives us an at least as brilliant interpretation of the author of “DieVerwandlung”, who would have guessed the concept of psychic transformation and would have used the “not designable” image of the “monstrous vermin” he invented ,to tell us about the transformation which can happen upon awakening, that is, at thetransition from sleep to wakefulness, the moment in which the consciousness reigns supreme. In the aforementioned introduction we then find the comparison betweenKafka’s opera and a written letter of the President of the Court of Appeal Schreber8.In the writing of his own hand Schreber talks about himself and about as “in a state between sleep and wakefulness”, “early in the morning” he had “the representation that it must be really nice to be a woman undergoing copulation”.We do not intend in any way to express moral judgments regarding the choice of these people nor to debate medico-legal issues, which are differently interpreted depending on the context. For instance changing name and gender on the identity card is rather easy in Germany9

, as well as undertaking hormonal therapies or surgery, even under 18 years of age sometimes. The issues mentioned above, however, remain unchanged and complex, even in this case.What seems relevant to us is to understand what to answer to Camilla, who introduces herself saying her name is John.

In this regard, the question contained in the first Fagioli’s Book “Death Instinct andKnowledge” is fundamental, and it should accompany every moment of our psychotherapy work with respect to patient communication:<< Do I understand what the patients are telling me? >>10.

The therapeutic relationship, even with its peculiar characteristics, is part of medicine, which is science, practice and art at the same time11. By merging these three dimensions we should be able, in front of Camilla, to wonder about what she istelling us, to decide whether to call her Camilla, or John, or whether to smile and not call her by name. This modulation of ours depends on the therapeutic relationship with that patient at that moment.Thanks to the Human Birth Theory we know that physical transformation does not exist. But we would never dream of telling the schizophrenic patient who tells us he hears voices at the beginning of therapy, not to worry, they do not exist, they are onlyhis invention, thus posing rational objections and not actually accepting the relationship with the unconscious12. Similarly, it does not occur to us to tackle the very complex issue of sexual identity in the first session, unless explicitly asked. But, even in this situation, we must any way evaluate in each single case if and how to respond. It is clear that the anagraphic and biological identity are a fact that cannot becanceled. But the relationship in the setting13 should involve the unconscious above all. During Collective Analysis14 Massimo Fagioli called the participants “red shirt”,”blonde” or “twenty years old” and treated them without knowing their names. The name was not used for the cure: the delusion disappeared anyway, as well as the provocative or hysterical attitude.


  1. Goodman M, Adams N, Corneil T, Kreukels B, Motmans J, Coleman E. Size and Distribution of Transgender andGender Nonconforming Populations: A Narrative Review. Endocrinol Metab Clin North Am. 2019Jun;48(2):303-321. doi: 10.1016/j.ecl.2019.01.001. PMID: 31027541.2
  2. Radix A. Hormone Therapy for Transgender Adults. Urol Clin North Am. 2019 Nov;46(4):467-473. doi:10.1016/j.ucl.2019.07.001. Epub 2019 Aug 19. PMID: 31582021; Rowniak S, Bolt L, Sharifi C. Effect of cross-sexhormones on the quality of life, depression and anxiety of transgender individuals: a quantitative systematicreview. JBI Database System Rev Implement Rep. 2019 Sep;17(9):1826-1854. doi: 10.11124/JBISRIR-2017-003869. PMID: 31021971; Karalexi MA, Georgakis MK, Dimitriou NG, Vichos T, Katsimpris A, Petridou ET,Papadopoulos FC. Gender-affirming hormone treatment and cognitive function in transgender young adults: asystematic review and meta-analysis. Psychoneuroendocrinology. 2020 Sep;119: 104721. doi:10.1016/j.psyneuen.2020.104721. Epub 2020 May 31. PMID: 32512250; Zurada A, Salandy S, Roberts W,Gielecki J, Schober J, Loukas M. The evolution of transgender surgery. Clin Anat. 2018 Sep;31(6):878-886. doi:10.1002/ca.23206. Epub 2018 Oct 20. PMID: 29732618.
  3. https://massimofagioli.com/teoria-della-nascita/
  4. M. Fagioli, “Se avessi disegnato una donna” in Bambino donna e trasformazione dell’uomo (1980), L’Asinod’oro edizioni, Roma, 2013, pp. 29-64.
  5. ivi
  6. ivi, p. 61.
  7. F. Kafka, Die Verwandlung, pubblicato per la prima volta in Die Weißen Blätter, Eine Monatsschrift. Hrsg. VonRené Schickele, Jg. 2 (1915), H. 10 (Oktober), S. 1177–1230.
  8. Nel 1903 il presidente della Corte d’Appello di Dresda Daniel Paul Schreber pubblicò a proprie spese un libro,intitolato Memorie di un malato di nervi, in cui descriveva con particolare vividezza e precisione I propri deliriparanoidi. Dell’importanza di quest’opera si accorse Carl Gustav Jung che, nel 1910, lo fece leggere a Freud, ilquale utilizzò questi scritti, facendo di essi un famoso caso clinico: S. Freud, “Osservazioni psicoanalitiche su un caso di paranoia(dementia paranoides) descritto autobiograficamente (Caso clinico del Presidente Schreber)(1910)”, Opere vol. VI, Bollati Boringhieri, Torino, 1986 – 1980, pp. 335-406.
  9. M. Sittner, Gendermedizin. Zeit für gute Neuigkeiten, in Deutsches Ärzteblatt, Jg. 119, H.8, 25.02.2022, p.324.Cfr. Anche: https://dgti.org/2021/09/05/der-ergaenzungsausweis-der-dgti-e-v/. Per l’Italia cfr. il DecretoLegislativo del 1 settembre 2011, n. 150 Disposizioni complementari al codice di procedura civile in materia diriduzione e semplificazione dei procedimenti civili di cognizione, ai sensi dell&#39;articolo 54 della legge 18 giugno2009, n. 69 (11G0192).
  10. M. Fagioli, Istinto di morte e conoscenza (1972), L’Asino d’oro edizioni, Roma, 2017, p 31. Cfr. anche, ivi,Cap.1 “La fantasia di sparizione. 14: <<Ritengo invece che tutto ciò che accade in analisi, vada consideratonell’ambito della relazione globale, cosciente e inconscia, del paziente verso l’analista (transfert)e dell’analistaverso il paziente (controtransfert). >>
  11. P. Fiori Nastro, Le origini del metodo medico in La medicina della mente, di A. Masini, D. Colamedici, G.Roccioletti, L’Asino d’oro edizioni, Roma, 2011, pp. 65 – 72 e Marcella Fagioli, Le origini del metodo psichiatrico,ivi, pp.72 – 85.
  12. Cfr. M. Fagioli, La psichiatria come psicoterapia, L’Asino d’oro edizioni, Roma, 2021.
  13. Ivi e M. Riggio, Il setting e e A. Piazzi Il transfert in La medicina della mente, di A. Masini, D. Colamedici, G.Roccioletti, L’Asino d’oro edizioni, Roma, 2011, pp. 189 – 208.
  14. https://massimofagioli.com/analisi-collettiva/


  • Goodman, M., Adams, N., Corneil, T., Kreukels, B., Motmans, J., & Coleman, E. (2019). Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review. Endocrinology and metabolism clinics of North America48(2), 303–321.
  • Karalexi, M. A., Georgakis, M. K., Dimitriou, N. G., Vichos, T., Katsimpris, A., Petridou, E. T., & Papadopoulos, F. C. (2020). Gender-affirming hormone treatment and cognitive function in transgender young adults: a systematic review and meta-analysis. Psychoneuroendocrinology119, 104721.
  • Radix A. (2019). Hormone Therapy for Transgender Adults. The Urologic clinics of North America46(4), 467–473.
  • Rowniak, S., Bolt, L., & Sharifi, C. (2019). Effect of cross-sex hormones on the quality of life, depression and anxiety of transgender individuals: a quantitative systematic review. JBI database of systematic reviews and implementation reports17(9), 1826–1854.
  • Zurada, A., Salandy, S., Roberts, W., Gielecki, J., Schober, J., & Loukas, M. (2018). The evolution of transgender surgery. Clinical anatomy (New York, N.Y.)31(6), 878–886.
  • Fagioli, M. (2011). Le origini del metodo psichiatrico. In D. Colamedici, , A. Masini, , & G. Roccioletti,  (Eds),  La medicina della mente: Storia e metodo della psicoterapia di gruppo (pp.72 – 85). Roma: L’ Asino d’oro edizioni.
  • Fiori Nastro, P.(2011). Le origini del metodo medico. In D. Colamedici,, A. Masini, , & G. Roccioletti, (Eds),  La medicina della mente: Storia e metodo della psicoterapia di gruppo (pp. 65 – 72). Roma: L’ Asino d’oro edizioni.
  • Riggio, M.(2011). Il setting. In D. Colamedici, A. Masini, & G. Roccioletti,  (Eds),  La medicina della mente: Storia e metodo della psicoterapia di gruppo (pp.189 – 199). Roma: L’ Asino d’oro edizioni.
  • Piazzi, A.(2011). Il transfert.  In D. Colamedici, , A. Masini, , &  G. Roccioletti, (Eds),  La medicina della mente: Storia e metodo della psicoterapia di gruppo (pp.189 – 208). Roma: L’ Asino d’oro edizioni.
  • Fagioli, M. (1972). Istinto di morte e conoscenza (14th ed). Roma: L’ Asino d’oro edizioni.
  • Fagioli, M. (2021). La psichiatria come psicoterapia. Roma: L’ Asino d’oro edizioni.
  • Fagioli, M. (1980). Se avessi disegnato una donna. In M. Fagioli, Bambino donna e trasformazione dell’uomo (8th ed) (pp. 29 – 64). Roma: L’ Asino d’oro edizioni.
  • Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., et al. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7, International journal of transgenderism13(4), 165-232.
  • Freud, S., (1910).  Psychoanalytische Bemerkungen über einen autobiographisch beschriebenen Fall von Paranoia (dementia paranoides). Frankfur
  • t: Fischer (trad. it. Casi clinici, 6: Il presidente Schreber: osservazioni psicoanalitiche su un caso di paranoia (dementia paranoides) descritto autobiograficamente. Torino: Bollati Boringhieri, 2013).
  • Kafka, F. (1915). Die Verwandlung. Die Weißen Blätter, “2 (10)”, 1177–1230.
  • Sittner, M. Gendermedizin. Zeit für gute Neuigkeiten. Deutsches Ärzteblatt, “119 (8)”, 324.