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This is an account of my psychoanalytic work with Jozsef, a transgender patient assigned female at birth who ended psychoanalytic treatment abruptly after 1 year. The initial 3 months were three times weekly, then four times weekly for another 9 months. Presenting problems were depression and intense feelings of loneliness. Nothing in the patient's appearance and demeanour, as a 35-year-old man evoked the woman that he had been 10 years earlier. The analysand underwent a double mastectomy but did not dare to undergo genital reconstruction surgery. During his analysis, he described femininity as an illness that he felt the urge to fight off. Following Withers' (2020) framework of multi-level psychological distress evasion, the case illustrates how transgender identification and medical intervention may serve as an attempt to evade profound psychological distress, including attachment trauma and dysregulated affects. Jozsef showed the capacity for mental representation and symbolisation at certain times, but on other occasions, this capacity was lacking. Living with what he had done to his body was less unbearable for him than living with the annihilating suffering resulting from the sense of lacking a primary identity. As his analyst, I believed that the analytic task was to shift the focus from the external concrete reality of the body to bodily fantasies and psychic reality.