Patients with severe and prolonged symptoms of gender dysphoria are described as desperate or intensely compelled individuals who have a “frantic preoccupation” (Stoller and Herdt 1982) with opposite-gender hormonal treatment and sex reassignment surgery as solutions to their problem of being “trapped in the wrong body.” Many patients perceive psychotherapy as a potential obstacle to obtaining these two compulsively sought and valued treatments and may attempt to convince clinicians of the need for immediate hormonal and surgical intervention. In patients who mislead therapists about their histories or symptoms, the deceptiveness generally emanates from their belief that hormones and surgery are the only valid treatments through which they can achieve congruity between their inner gender and their anatomy (Lothstein and Levine 1981). Autocastration and impulses to perform genital self-surgery (Dixen et al. 1984; Hazelwood et al. 1983; Krieger et al. 1982; Lothstein 1992; Wise 1982) in the absence of psychosis (Favazza 1987) have been reported in patients who have not received psychotherapy or who have failed to obtain desired hormonal or surgical treatment.

Although some patients have little knowledge and understanding of their gender-dysphoric conditions, many others are well informed from a variety of sources: medical literature; clearinghouses for gender-related materials (e.g., International Foundation for Gender Education, Renaissance, The Outreach Institute); computerized bulletin boards, which, because of their anonymity, provide safe opportunities for the expression of cross-gender identity (e.g., Genderline, Transgen Digest, CD Forum Digest); and participation in awareness organizations and cross-dressing social and support groups (lists of which can be found in current issues of Tapestry Journal [P.O. Box 367, Wayland, MA 01778-0367]).

When patients’ level of knowledge about their condition surpasses that of the general psychiatrist (Brown 1990a), difficulties can ensue. The evaluator may be naively misled by a sophisticated presentation of self-diagnosed transsexualism. In addition, patients, in their desperation, have been known to falsify histories, forge documentation, be exploited by unscrupulous individuals willing to furnish credentials for cash, enlist a surrogate parent to pose as their real one, and even recruit a surrogate patient to report an invalid HIV status. These efforts are aimed at enhancing their chances of obtaining referral for hormonal or surgical treatment. Many gender clinic and private practice professionals seek independent verification of important aspects of a patient’s history by interviewing family members and friends and by reading original documents and records (Brown 1990a; Fisk 1973; Wise 1982). Some practitioners also feel that adequate diagnostic assessment of patients requires the interviewing of significant others (Levine and Lothstein 1981), whereas others feel that any possible benefits to be gained from such a practice should be considered on a case-by-case basis (Schaefer and Wheeler 1985, 1989).