How might one account for the discrepancies between the results of the clinical interview. which agreed with the patient's self reports that Tina was stable and rehabilitated post SRS, and the results of the psychological testing? Was this an example of a folie a deux between therapist and patient? Or were the results of the psychological testing being taken too seriously?

Of particular interest was Tina's use of transparent barriers to protect herself from intrusion. She perceived figures leaning on and reflected in a mirror, and "an odd animal standing on a plexiglass floor and a person looking up through the floor." While distancing her from a perceived threat, these responses also suggested a voyeuristic component of her object relationships by which she could participate with the feared and exciting object.

The second Rorschach, however, revealed a breakdown in Tina's control system. While she did provide twenty three responses, her F + % was 57 per cent (normal value, 80% < F + % < 90%), suggesting that her reality testing could, at times, be markedly impaired. Her extended F + % was, however, within normal limits (EF + % = 87%) and supported the initial findings of a subtle but intrusive thought disorder, which had a variable effect on her cognitive performance.

The second battery of psychological tests was administered a year after SRS. Initially, Tina kept up her facade, but eventually became quite depressed. She admitted that she had lied to her therapist about how satisfied she was with the phalloplasty because she did not want to "let him down."

Tina's sexuality and the primitive nature of her impulses seemed to disorganize her. By the end of the Rorschach test she became overwhelmed by the color (symbolizing her impulses and affects), and was unsuccessful in unifying the images. Her need to unify concepts and percepts suggested that she experienced herself as fragmented and in need to unification.

On the Thematic Apperception Test (TAT) Tina's stories were logical and coherent, contraindicating an overt psychotic thought disorder. While she tended to utilize fantasy and daydreaming as major defenses, she was able to organize the themes of the pictures without resorting to gross reality distortion. However, her object relationships were some what disturbed.

Talks with colleagues at other gender identity clinics revealed that complete psychological testing was rarely obtained because it was viewed as either too expensive or irrelevant to the diagnosis and treatment of transsexualism. In retrospect, both objections were really based on the fact that most gender clinics did not have any psychodynamically trained psychologists to administer or interpret such tests.

An MMPI which was administered revealed an 8 4/4 8 profile (with scale 5 being the third highest). The consultant, who was not a member of the gender identity clinic, summarized his findings by stating: "I would expect [the profile] to be associated with a female homosexual [and] in any case the point would be that there is not gross pathology here beyond the sex role identification problem."

Once Tina was conceptualized by the treatment team as an example of a "stable" female transsexual, her assessment and treatment were predetermined. In a personal communication Jon Meyer has described a woman like Tina whom the Johns Hopkins gender clinic deemed to be their most stable and reliable patient.

From a strictly DSM III standpoint Tina met all the criteria for a diagnosis of transsexualism. She exhibited a profound sense of gender discomfort and believed that she should have a male body. Indeed, she wished to be rid of her breasts and to have phalloplasty.