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). In the context of a disorganized and sexually chaotic family, Barbara failed to develop a core female gender identity. Her experience of a continual assault upon her normal female gender development led to profound gender diffusion and dysphoria throughout her life cycle.

Barbara was diagnosed on psychological tests as having a borderline personality disorder with impulsive and psychopathic features. Her male identifications were typically shallow and caricatured (similar to those held by latency aged girls who engage in role acting maleness). Each new life cycle epoch led to an increasing desire to obliterate her femaleness and consolidate her "maleness," sociologically characterized by role changes from transvestism, homosexuality, to transsexualism. Psychological testing supported the clinical interview diagnosis and highlighted Barbara's bright normal to superior intelligence which she used to enhance her male role impersonation.

From a clinical standpoint, Barbara lacked a cohesive self system, had an impaired body image and had a severe narcissistic personality and behavior disorder. At times her self system was fragmented and enfeebled. While she was preoccupied with grandiose, omnipotent, rescue fantasies she was unable to establish reasonable goals for her life. Each life failure increased her susceptibility to further narcissistic injury and personality fragmentation, and led to the emergence of incapacitating hypochondriacal symptoms. This was not a woman beset with penis envy, masculinity complex, or castration anxiety, but one with a severe developmental disorder and a primary narcissistic personality and behavioral disorder.