As the number of applicants for SRS grew, so it became apparent that patients were requesting SRS for a variety of gender identity and role disorders. The diagnosis of transsexual became synonymous with SRS. What did these requests mean? Why would non transsexuals even request SRS? The situation was made more complex by the proliferation of patients requesting SRS and the increasing numbers of clinics set up to evaluate and treat self labeled transsexuals. The burgeoning literature on transsexualism also suggested that the wish for SRS might be a diagnostic factor in its own right and independent on the diagnosis of transsexualism. It appeared as if many individuals with a chronic, but latent gender identity or role conflict could, under intense stress, come to believe that a change of sex could cure their problems. Clearly, this group of patients was significantly different from Stoller's depiction of the true male transsexual. Moreover, as transsexual issues were sensationalized and oversimplified by the media, many patients came to see a solution to their human suffering in terms of sex reassignment surgery.

It has become common knowledge that some effeminate homosexuals might, at the instigation of fellow homosexuals, or under the stress of a personal relationship that was threatened with collapse, be persuaded to undergo SRS (only to regret it later). Other patients labeled sexual psychopaths, sadists, masochists, psychotics, schizophrenics, or as having organic pathology, might also request SRS during a period of intense stress (functional or organic) and might experience a personality deterioration or decompensation. Such individuals have been labeled as non transsexuals or secondary transsexuals. But in light of a lack of consensus about the meaning of the term transsexualism, do these categories tell us any more than that the person should not be referred for SRS? Apparently so, since at least one gender identity clinic team (Laub and Fisk, 1974) has suggested that some non transsexuals (i.e. non primary or true transsexuals) might benefit from SRS (Fisk, 1978). To the interested clinician, no less to the curious lay observer, the diagnostic situation in transsexual ism must appear confusing at best.