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.

In contrast to Tina's family, Barbara's family revealed considerable evidence of emotional pathology. Both women, however, successfully impersonated men and presented a "stable" facade. For Barbara, however, once her family history was acknowledged it was difficult to view her as a "stable" female transsexual. Yet she was reliable. She kept all of her appointments; had a 100 per cent attendance rate for her therapies; paid all her bills; was never obnoxiously demanding or impulsive to hospital staff; and was viewed as a likeable individual who had a stable instability. She split off her impulsivity and chaotic life experiences from the clinic and was never viewed by the staff as unstable apart from what she told us about her personal life. In other words, there was a huge discrepancy between her clinical self presentation and her reported social history and life style outside the therapy hour (typical of patients with borderline personality disorders). While one might try to explain Barbara/Brian's conflicts as related to her low social class, such an explanation is too simplistic.

Barbara's case history was typical of a large subgroup of self labeled female transsexuals. Typically, these women appear to have two distinct lives. In therapy they are viewed as compliant, cooperative, good natured and "stable." Their lives outside of therapy, however, are usually quite chaotic and disorganized, with bizarre family histories and behavior which is generally viewed as psychopathic, impulsive, and alcoholic.

There are several possible explanations for understanding the basis for Barbara's transsexualism. On the one hand, her personality conflicts can be attributed to her transsexualism; one may argue that once Barbara obtains hormone therapy and SRS all her physical symptoms and emotional anguish will be resolved. On the other hand, her transsexualism may be an epiphenomenon of her inter-generational family pathology and enmeshed family dynamics (that is, her symbiotic relationship with her mother) which supported her gender identity conflicts.

It is compelling to view the inter-generational family dynamics as playing a crucial role in the formation of Barbara's gender identity conflicts. Indeed, it was within the family context of two generations of child abuse, chaotic sexuality, and gender identity pathology, that Barbara failed to develop a female core gender identity. From birth, Barbara experienced a continual assault upon her gender identity and role development. Her mother wished for a boy, hated girl children, and communicated to Barbara that only as a boy would mother love and accept her. Moreover, mother surrounded herself with men who crushed Barbara's female gender development and encouraged her to develop as a boy, the stepfather even going so far as to give her a male name and introduce her as "my son." Barbara was not provided the proper milieu in which to form an appropriate female core gender identity. Indeed, there seemed to be a family conspiracy to masculinize Barbara. The result was that she had a disposition for gender diffusion and gender dysphoria which was exacerbated by stressors throughout her life cycle. (see THE FORMULATION OF BARBARA'S DIAGNOSIS OF TRANSSEXUALISM PART II)