When doctor met with Mr. France (Samuel) he was accompanied by his wife Rachel. (He had adopted France as his family name.) They were a striking couple -- tall, attractive, dark haired, severe, and earnest. Both had their heads covered, typical of members of Orthodox Jewish sects.

The role of the family in the dynamics of female transsexualism is often obscured by the fact that either the parents are unavailable or they refuse to cooperate in their daughter's transsexual evaluation.

The brother, who was visiting family in the US, was anguished by his sister's transsexualism. At the root of his concern was his struggle between his religious orthodoxy, his love for his sister, and the fear that he would be forced to reject her formally for violating God's law. He wrote: ...

Barbara's history revealed that her wish to become a man was multi determined: supported by intrapsychic mechanisms, family dynamics and interpersonal processes. Her gender identity pathology could be traced back two generations (in which all the women in the family had evidenced serious gender identity or role pathology).

Typically, Barbara had great difficulty setting limits, and in organizing her life into a routine. Her chaotic early childhood history had left her without a mechanism to modulate and regulate her affects and impulses. Consequently, she responded to stimuli impulsively and reflexively, with no awareness of the impact she had on other people.

By employing primitive defense mechanisms such as denial, splitting, projection, projective identification, omnipotence, Barbara split off the bad mother image and was thereby able to continue her relationship to mother. However, her conduct vis a vis mother was one of complete helplessness and masochistic submission: always explaining away, or denying, mother's bad behavior and justifying mother's aggression towards her.

Barbara's early developmental history was replete with losses, separations, abandonments, and deaths. These events seemed to mobilize her intense separation anxiety and dread of abandonment, leaving Barbara vulnerable to profound depressive crises (which were acted out through self destructive behaviors).