By 1953 it was clear that female transsexualism was not isolated to a few rare cases. After the celebrated Christine Jorgenson case, Hamburger (1953) reported that 108 women sent him letters from all over the world requesting SRS. The age distribution ranged from 15-55, with the ratio of females requesting information being 1:4. Only one of the women reported being married and six were divorced. All the women reported homosexual desires and none mentioned having attractions to men. Twenty three per cent of the women reported having masculine features which they thought contributed to their views of themselves as male. Hamburger concluded that "in women who feel like men the wish for a change of sex does not seem to manifest itself or become dominant until the person in question falls in love with another woman; this happens in the great majority of cases."

Barahal (1953) presented a lengthy case of a 22 year old woman who requested SRS whom he diagnosed as being transvestitic. The patient was illegitimate and had "never seen her real father and only recently had learned who he was." The mother, succumbing to the gossip of the local villagers, "rejected the patient very early in life, and began to board her with various friends and relatives." Barahal listed at least nine major changes and moves in the patient's life up through age 14. The patient had a ninth grade education. Since early childhood "she had an ungovernable desire to be a boy and had insisted on wearing boy's clothing." The analysis, which was reported up through the 154th session, was partially conducted while the patient was hospitalized. The case study was important because of the detailed presentation of the patient's therapy (in a session by session format). Barahal concluded that there was a close "relationship between her insatiable drive for masculinity and her early relationship to her mother or mother substitutes." The patient was seen as viewing the woman's role as "disadvantageous and dangerous." Indeed, the patient was molested by several men, including a relative, and, as a woman, perceived herself as being vulnerable to male aggression. The mother repeatedly told the patient that had she been born a boy she could have cared for her mother in a more protective manner. The patient learned that "in order to obtain her mother's love she had to be a boy." Early in life the patient was seen as competing with men "for the love of the mother, even to assuming a man's attire." Barahal concluded that "female transvestism, therefore, is not a manifestation of homosexuality but of a drive for masculinity."

Barahal was the first clinician to consider the preoedipal attachment of the child to its mother as a possible determining force in the evolution of a gender identity disturbance. He also supported Redmount's findings (though he did not cite him) that the female transsexual's mother needed to be protected, while encouraging an unconscious male fantasy in her daughter to take over the husband's role. In addition, Barahal suggested that early childhood separations and losses may have compromised this woman's ego development and led to her ego diffusion and/or gender identity confusion (especially in her magical thinking that dressing in male clothing made her a "real" male). Barahal also suggested that non conflictual learning processes in early childhood may be a causal agent in the development of adult gender identity and role disturbances. (see TRANSSEXUALISM: CROSS CULTURAL INFLUENCES (1940-80) PART III)