The formulation of Barbara's diagnosis of transsexualism was gleaned from several sources: transcripts from her long term individual, group, and family therapy; intensive psychological testing; interviews with family members, children, lovers, and friends; and post operative follow up data up to four years post surgery.

Eventually, Barbara found a man willing to impregnate her (but refused to reveal his identity, thereby recreating for her daughter the same mystery that surrounded Barbara's own birth). At the time of the delivery, Barbara told the nurses about her situation and they arranged for Arlene to take her place in bed and be wheeled out of the hospital with little Arlene (the child was named after her).

Barbara returned for Richard when she began living in a stable lesbian relationship. Her lover, Donna, was an impulsive, violent woman who hated men and viciously abused Richard (physically and psycho logically). The relationship lasted almost eight years (though Barbara had innumerable lesbian affairs throughout the "marriage"), and terminated with the death of Barbara's stepfather.

During her fourteenth year Barbara became increasingly self absorbed by her male daydreams (in which she pictured herself as a male hero rescuing women in distress). Because she had withdrawn from school, her male daydreams were reinforced, as her stepfather related to her as a "pal."

When Barbara was 12 she had her first homosexual experience. During preadolescence, however, she had engaged in extensive petting and masturbation with both boys and girls. Her sexual drive was experienced as uncontrollable, completely dominating her life, involving her in compulsive daily masturbation accompanied by rituals and intrusive sexual fantasies. These practices and fantasies interfered with her ability to concentrate at school.

During childhood Barbara had identified as a tomboy, a behavioral pattern which was reinforced by the stepfather. She did, however, have girlfriends and played girls' games (recalling that she wanted to be near her girlfriends because of the intense sexual feelings she had for them).

Throughout Barbara's childhood, mother had a series of tandem relationships which exposed Barbara to confusing sexual and aggressive experiences. Mother virtually abandoned Barbara to the stepfather and was either out partying with men, engaged in alcoholic binges, or at work (where she was employed as a salesperson). Barbara recalled feeling constantly abandoned by mother, but also feeling the need to cling to her.

Barbara remembered very little of her early childhood. She was told that her father; of Italian ancestry, had abandoned the family prior to her birth (but there are no records that mother ever married the man). Mother, an impulsive, paranoid, disorganized woman, told Barbara that during her pregnancy with her she prayed for a boy and was depressed and disappointed when she delivered another girl baby.

It was hard to believe that the cocky, self assured "male" sitting in the waiting room was really a biological female. Introducing herself as Brian, she demanded hormones and surgery and stated: "I'm a man trapped inside a woman's body. I'm in desperate need to match my body with my mind, the real me inside.

Of the fifty three women, full psychiatric diagnoses were obtained for forty six. The other seven patients had MMPI diagnoses, but they had not remained in treatment long enough for a thoroughgoing diagnosis to be established. Most of the diagnoses resulted from a consensus opinion of our clinic staff.