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. She was constantly subject to being over stimulated, impulse ridden, and disorganized. The emotional cost of her early childhood history included precocious ego development in some spheres but generally retarded ego development, with manifest ego impairments and non specific ego weaknesses.

It would appear that while Barbara's stepfather was alive his presence made her gender identity conflicts tolerable and shielded her from a severe depressive crisis. When he died, Barbara's depression over his death was expressed by her wish to fuse with him and become a man thereby keeping him "alive." His death must have concretely symbolized her annihilation: that is, the death of her "good" or "male" self.

About the time the stepfather died Barbara's son Richard was entering his adolescence. Barbara experienced Richard's puberty traumatically, as signaling her ultimate defeat. She was profoundly jealous of Richard's developing masculinity and the growth of his penis. In an apparent effort to emasculate him, Barbara dressed him as a girl for a Halloween party. Richard's reaction was predictable. He became panicky and delusional, believing that he was uncontrollably turning into a woman in this case the Bionic Woman. By driving her son crazy with her intention of becoming a man, and depriving Richard of his birthright, Barbara may have externalized her gender conflict for good, thereby sealing off her conflicts from psychotherapeutic intervention.

The relationship between stressful life events and Barbara's transsexualism was clear cut. Throughout her life she had reacted to losses, changes, separations, abandonments, and deaths with wishes for sex change. For example, Frances's removal from the home, the death of the grandfather, Richard's entry into adolescence, and the death of the stepfather all led in varying degree to Barbara's experiencing intense gender dysphoria, the belief that she was male, and her wish for SRS.

The childhood belief that she had a penis inside her vagina, while common fantasy among girls, was given a special reality by Barbara. The fantasized penis seemed to protect her against profound castration threats and abandonment fears (which she associated with being female). Moreover, the "penis" probably symbolized the stepfather. In trying to obtain a penis, Barbara was acting out a fantasy that the penis = maleness (a crude version of an early childhood cognitive formulation that sexual differentiations are made on the superficial basis of clothes and hair). Mother reinforced Barbara's fantasy by making her believe that something mysterious was associated with her birth and her father. Moreover, mother had wanted a male child. When Barbara received SRS she nurtured her new penis in a tender way, cradling it, as if it were a new born child. Indeed, her reaction suggested that the penis symbolized her childbearing capabilities and represented a tender part of herself which could only emerge after SRS, in a distorted, caricatured, masculine way.

For Barbara, growing up as a female was dangerous, entailing separations, losses, abandonments, and possible annihilation. Barbara was unable to repress her wishes for a penis for several reasons: her parents actively supported that wish; and it was not simply related to oedipal issues or a neurosis, but was profoundly tied to her sense of self identity and her very existence. Indeed, one may speculate that Barbara's inability to develop a female core gender identity was inextricably related to her early ego impairments and developmental defects. Each successive life cycle challenge further stressed her already overburdened self system in terms of increased gender dysphoria. (see THE FORMULATION OF BARBARA'S DIAGNOSIS OF TRANSSEXUALISM PART V)