Beginning in August 2007, we committed ourselves to a clinical review the co-morbid diagnostic patterns of the last 10 patients interviewed by our Gender Identity Clinic. We found 90% of these diverse patients had at least one other significant form of psychopathology. This finding seems to be in marked contrast to the public, forensic, and professional rhetoric of many who care for transgendered adults. Much of this rhetoric sounds remarkably certain about the long-term value of gender transition, hormones, and sex reassignment surgery in improving the lives of those with Gender Identity Disorder (GID). Such clinical certainty would have to be based on carefully established sophisticated follow-up findings. These are lacking. The psychopathologies in this series included problems of mood and anxiety regulation and adapting in the world. Two of the 10 have had persistent significant regrets about their previous transitions. In discussing management decisions, civil rights, and ethics, we planned to separately briefly present the 10 patients. However, our decision to seek patients' permission proved so upsetting to three of the first six patients that we altered the structure of this report. Our attempt to follow the ethical principle of informed consent caused us to violate the principle of nonmalfiescence. This distressing experience only illustrates, however, the disadvantage of discussing professional concepts with lay audiences. Emphasis on civil rights is not a substitute for the recognition and treatment of associated psychopathology. Gender identity specialists, unlike the media, need to be concerned about the majority of patients, not just the ones who are apparently functioning well in transition.

Within the transgendered community, the use of the term psychopathology for the diagnoses of Gender Identity Disorder (GID) and Gender Identity Disorder Not Otherwise Specified (GIDNOS) is often, although not invariably, greeted with outrage. Not only does this complicate productive dialogue between lay and professional audiences, it skews what is publicly said about these problems. Changing of sex and gender is a magnet for a media that feeds the public's interest in this phenomenon. From a mental health clinician's perspective, the transgendered pose difficult management and ethical challenges. These challenges provide one explanation for why only a relatively small proportion of psychologists, sex therapists, and physicians are willing to work with this group of patients. From a public policy point-of-view, the transgendered represent a civil rights issue. These three forces—management decisions, ethical considerations, and civil rights—ideally can interact to help society and the patient advance. Occasionally the three forces clash loudly (Carey, 2007 Carey, B. 2007. Criticism of a gender theory, and a scientist under siege. The New York Times, : D1D6 August 21, 2007). Most of the time, however, they meet inconspicuously and subtly generate fog for both patients and professionals. We aspire to eliminate some confusion by examining the meaning of the term psychopathology in order to assist those who are interested in working in this professional arena. We will make four major points: 1. in a nosological sense, GID are forms of psychopathology; 2. gender identity disorders are typically co-morbid with other psychopathologies; 3. the promotion of civil rights for the transgendered can obscure professional perceptions of psychopathology; 4. ethical obligations require professionals to communicate the uncertainties about the long-term outcome of gender transition and sex reassignment surgery (SRS). This project was stimulated by the editorial in this journal suggesting that more research is needed to revive the vitality of clinical sexuality (Rowland, 2007 Rowland, D. 2007. Will medical solutions to sexual problems make sexological care and science obsolete?. Journal of Sex and Marital Therapy, 33: 385–397. ). We committed ourselves to consecutively review the 10 most recently seen and discussed patients at our Gender Identity Clinic. We hypothesized that this descriptive method might capture the actual complex problems we face when we perceive that a patient qualifies for a diagnosis of a gender disorder (Levine, 2007). This review, which described the patients at one point in time, revealed that 9 of the 10 patients had significant current associated psychopathology. After this article was written, the authors attempted to contact each patient to approve of their case history. This was felt to be the ideal ethical approach because it respected the principle of informed consent. We were careful to first provide an accurate description and, after approval, to disguise the patient. This approach demonstrated to us how many historical details were in error. Three of six patients corrected some facts and provided permission. Three, however, were incensed, demoralized, and felt betrayed by what we said about them. One crestfallen 20-year-old male said, “So that is what you think of me!” Because of the possibility of even more harmful reactions, we elected to present the article without six of the case illustrations. Our dilemma between pedagogical freedom to contribute to the literature and patients' rights to privacy is not unique to gender patients (Levine & Stagno, 2001 Levine, S. B. and Stagno, S. 2001. Informed consent for case reports: The ethical dilemma between right to privacy and pedogogical freedom. Journal of Psychotherapy: Research and Practice, 10: 193–201. ; Pies, 2007 Pies, R. H. 2007. Writing about patients: The perennial problem. Psychiatric Times, ).

WHY ARE GID CLASSIFIED AS PSYCHOPATHOLOGIES? In order to grasp the answer to this question, it is necessary to have some understanding of nosology and the limitations of the concept of mental illness. Nosologies, the systems of classification of disorders, change through advances in both science and culture. Science changes them via breakthroughs in understanding of the pathogenesis of disease and through new understandings of nosology itself (Kendell & Jablensky, 2003 Kendell, R. and Jablensky, A. 2003. Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160: 4–12. ). Culture revises them as social assumptions about a condition evolve. Cultural influences, which are usually derived from outside of psychiatry, are conceptual, political in nature, and powerful. In American psychiatry, the Diagnostic and Statistical Manual (DSM) has undergone four revisions in a generation—1980, 1987, 1994, 2000. Most revisions were driven by changing assumptions about mental illness. Through the World Health Organization, the International Classification of Diseases (ICD) has been updated nine times. These systems, although similar, are not identical and they are not the only way of viewing what is and what is not mental illness (Hinshaw, 2007 Hinshaw, S. P. 2007. The mark of shame: Stigma of mental illness and an agenda for change, New York: Oxford University Press. ). What is Psychopathology? “Psychopathology” is a generic term. One hundred years ago, it referred to any form of psychosis, neurosis, or ordinary impairment of memory, speech, writing, and behavior produced by the unconscious mind (Freud, 1901 Freud, S. 1901. The psychopathology of everyday life (Vol. VI), London: The Hogarth Press. ). Later it came to include any new problem that emerged into social awareness, such as post-traumatic stress disorder or autism. As psychiatric research and education became more focused on the devastating forms of psychiatric impairments in recent decades, psychopathology took on more ominous connotations. When the neuroses were redefined as Anxiety and Mood Disorders in 1994, these renamed problems became psychopathologies. Psychopathology denotes any category in a nosology for which a patient's history qualifies him or her when accurately diagnosed by a mental health professional. Gender Identity Disorder (GID) as a form of psychopathology in this sense is no different from Social Anxiety Disorder, Attention Deficit Disorder, Dysthymia, or Narcissistic Personality Disorder. Each of the psychopathologies carries with it significant disadvantages. Each has a different pattern of subjective suffering such as distress or impairment of expected capacities—i.e., learning, socializing, working, relating, thinking, and preserving health and life. These incapacities range from devastating to bothersome, from life threatening to efficiency threatening, from ever present to episodic, from obvious to hidden, and from maladaptive to dysfunctional. None of the diagnostic entities is trivial. The lifetime prevalence of mental disorders in the general population approximates 50% (Kessler, Berglund, Demler, Jin, & Walters, 2005 Kessler, R. C., Berglund, P., Demler, O., Jin, R. and Walters, E. E. 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey replication. Archives of General Psychiatry, 62: 593–602. ). Professionals use psychopathology interchangeably with mental disorder, emotional disorder, psychiatric disorder, mental illness, and emotional illness. The term and its synonyms convey no information about severity, course, or treatment and they have no single all-inclusive definition (Hinshaw, 2007 Hinshaw, S. P. 2007. The mark of shame: Stigma of mental illness and an agenda for change, New York: Oxford University Press. ). When patients with any diagnosis learn that they have a mental illness, they may feel stigmatized—that is, privately they feel shock, shame, and degradation. They previously may have thought that they only had a “problem” or an “issue.” Validity Limitations The mental health professions and institutions of culture, such as the courts and insurance companies, find nosologies necessary for efficient communication, education, treatment, payment, administration, and research. Nosologies are imperfect systems. Psychopathology and its synonyms are large umbrella terms that specify the presence of some specific problem which in turn is defined by criteria. Official disorders are not absolute realities (Zachar & Kendell, 2007 Zachar, P. and Kendell, K. 2007. Psychiatric disorders: A conceptual taxonomy. American Journal of Psychiatry, 164: 557–565. ). They only seem to approximately describe patients' current or long-term lives. They have indistinct boundaries and while they have good inter-rater reliability, they may not validly capture the underlying mental problem they purport to describe (Horwitz & Wakefield, 2007 Horwitz, A. V. and Wakefield, J. C. 2007. The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder, New York: Oxford University Press. ; Kendell & Jablensky, 2003 Kendell, R. and Jablensky, A. 2003. Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160: 4–12. ). A person who meets criteria for a depressive disorder, for example, may after only several sessions, be better diagnosed as having an anxiety or an attention deficit disorder. The Answer Over a generation, committees of mental health professionals have reaffirmed that GID are commonly associated with subjective suffering or distress, functional impairments, and adaptive disadvantages. Like most psychiatric diagnoses, no biological etiology has been identified to explain their presence.

THE ADVANTAGES OF THE CONCEPT OF PSYCHOPATHOLOGY There are three advantages to the designation of a pattern of behavior as a disorder. The first is that professionals with a scientific background are more likely to study the origins, consequences, and treatment of disorders than other patterns. Scientific study offers the possibility of new knowledge and efficacious treatment based on evidence. The second is that third-party payment for evaluation and therapy services is linked to diagnoses. There is no insurance coverage for unofficial problems. The third is that some of the suffering attendant to these patterns can be ameliorated. Case #1, Ashe, adopted at 2 days, is now an 18-year-old female-to-male with GIDNOS. He has been in psychiatric treatment most of his life, including a residential stay for 9 months because of aggressiveness at age 13. Obviously extremely bright, he read at age 3 and now feels he knows a great deal about most things. After a highly problematic first 2 years of life, he was eventually recognized as having a severe form of a Sensory Neural Integration Disorder. Years of specialized treatment seemed to enable Ashe to tolerate human and fabric touch. His behavior at various times has led to six different psychiatric diagnoses. He is now medicated for Tourette's syndrome and bipolar disorder. He has been repudiating his gender since early in his life. He was envious of his mother when she underwent a hysterectomy when he was 9. He has been an avowed sexual sadist since he was in early grade school when his unhidden masturbation involved all manner of dominance and physical pain-causing humiliations of stuffed animals and imagined partners. He plans to matriculate at college as a male. When he began endocrine therapy, his appearance became increasingly feminine and bizarre. After 3 months, however, he began dressing in a more masculine fashion. He still rages at home at times but he is now far less disruptive socially. The Challenge of the Gender Patient's Psychopathology A GID, which is by definition a psychopathology, may travel with, in individual patients, other forms of psychiatric or neural developmental conditions. The patient's gender identity disorder is not exactly the challenge for the clinician. The challenge is the GID as it occurs in this person who may historically and currently have other forms of psychopathology.

THE POLITICAL DISADVANTAGE There is one major unfortunate disadvantage of the term psychopathology. This professional concept is widely misunderstood by the lay public. Some transgendered persons vehemently object to the categorization of severe gender problems as mental illnesses. Transgender phenomena may seem natural to them. Even if they recognize it as unnatural, however, they can take offense at being designated as disordered. They feel that “psychopathology” casts aspersions on them, alienates them from others, and socially prejudices others against them. In the transgender community, the fact that GID can be found in a nosology can be a lightning rod for antipathy towards those who diagnose them. The transgendered often look to the humanities for validation of their view and to political activism through gay-lesbian-bisexual-transgender coalitions to end the stigmatization. Removal of these diagnoses is viewed as a civil rights struggle, part of the larger flow of the human rights movement. They point to the 1973 precedent of the removal of homosexuality as a diagnosis. The argument that GID is not a psychiatric diagnosis because its cause is biological has been articulated in the absence of compelling data (Society (GIRES), 2006) Society (GIRES), G. I. R. a. E. 2006. Atypical gender development: A review. International Journal of Transgenderism, 9: 29–44. . It is hard to imagine professionals who work with gender patients who oppose their civil rights. When a person chooses to transition, clinicians try to facilitate their success. Professionals recognize that a gender identity diagnosis conveys that the development of the first psychological component of the patient's sexual identity—gender identity—did not occur in the manner of the vast majority of individuals and that this phenomenon typically has profound social and psychological consequences for the transgendered person. These consequences sometimes appear as associated psychopathology. The gender psychopathology and the problems that may accompany it are not, per se, civil rights issues. So when we are asked, “Why do you clinicians employ a term that offends the very people whom you say you are trying to assist?” a succinct answer may not be understandable. When organizations mix audiences of the transgendered and professionals, professionals are not free to have an in-depth discussion of the issues. Social forces then conspire to create a gender identity problem that is not a psychopathology and has no significant associated psychopathologies. This political correctness can easily befuddle or drive away professionals who are aware that the concepts of psychopathology and civil rights are separate matters.

REMOVING GID AND GIDNOS FROM THE DSM OR ICD The alternative to designating GID and GIDNOS as psychopathologies is to understand them as simply variations in the range of the patterns of gender expression among humans (Devor, 1997 Devor, H. 1997. FTM: Female-to-male transsexuals in society, Bloomington, IN: Indiana University Press. ; Hill, Rozanski, Carfagnini, & Willoughby, 2007 Hill, D. B., Rozanski, C., Carfagnini, J. and Willoughby, B. 2007. Gender Identity Disorders in childhood and adolescence: A critical inquiry. International Journal of Sexual Health, 1: 95–122. ). They are, of course. In their subjectivity, eroticism, and behavior many individuals explore gender themes throughout most of their lives. It would be illogical to remove these disorders based on the existence of a range of gender expressions, however. All psychopathologies are arbitrary designations that separate extreme ends of large spectra of behavioral, subjective, and adaptive patterns. Panic Disorders occupy one end of a large range of how people episodically experience anxiety. Alcoholism is one end of a large range of how people use alcohol. Gender disorders are one end of a pattern of acceptance and comfort with the anatomic self. All diagnoses arbitrarily draw lines between the ordinary and the extraordinary, the common and the rare, the adaptive and the maladaptive. Many people with gender variations eventually express interest in transforming their bodies by using medications and having surgeons alter the appearance and function of various body parts. Physicians do what they do either to treat disorders or to enhance patients' aesthetics. Historically, endocrine and surgical treatments were forcefully argued as required to diminish suffering and improve function in the world. Various versions of the Standards of Care reiterated that the treatments were not merely aesthetic procedures. Concerns about one's appearance are thought of as adaptive challenges to be typically dealt with by nonmedical means. Physicians ethically justified their work with gender patients by thinking it was the compassionate treatment of illness. Depathologizing the gender disorders will, we suspect, induce more ethical discomfort in mental health professionals, endocrinologists, and surgeons. Ethical discomfort is one of the main reasons that mental health professionals lose their confidence about their ability to think clearly when they discover that their patient's gender is atypical. We provided consultation to Case 2 (omitted) the patient, his parents, and his mental health professionals when the 20-year-old revealed that he planned to become a woman. The young man had been treated for 6 years for schizoaffective disorder. Based on our recommendations, treatment's focus became “increasing his competence in the world” rather than on his gender. At his 6 month follow-up, the patient was doing much better in the world; his feminine expressions were diminishing. If GID and GIDNOS were to disappear from the nosology, gender patients would request and obtain services without psychiatric scrutiny. This might prove imprudent and dangerous for some. If hormones and surgery were only matters of aesthetic enhancement, third-party coverage for mental health and endocrine services would likely disappear overnight. Also, progress in approving national coverage outside of the United States for sex reassignment surgery, such as recently occurred in Brazil, would not occur (“Brazil: Free Sex Change Operations,” 2007 2007. Brazil: Free Sex Change Operations. The New York Times, August 18: A4). Treatments and their outcomes might receive even less follow-up and careful scrutiny than they do today(Lawrence, 2003 Lawrence, A. A. 2003. Factors associated with satisfaction or regret following male to female sex reassignment surgery. Archives of Sexual Behavior, 32: 299–316. ). Momentum The motive for removing these disorders from nosologies is the belief that it will make life easier for those who have transitioned. The field, driven by institutional support for the transgendered and by the Internet, is already evolving in the direction of depathologizing the rhetoric of care delivery. The transgendered are now better organized, better informed, and more empowered to remove the mental health professional and endocrinologist from the process and to directly contract with surgeons for the procedure of their choice. They are already obtaining cosmetic surgeries without psychiatric consideration prior to genital surgery. Prior to the Internet, clinicians occasionally would be threatened with suicide if they did not grant hormones or sex reassignment surgery when they were desired. Today, patients sometimes threaten with, “If you won't give me hormones now, I will just get them through the Internet.” Case 3 (omitted) issued this threat which was skillfully worked through by discussing over three sessions his fears about taking estrogen without competent medical supervision. The momentum created by the broadening social, vocational, and legal rights of those who have transitioned is one of several important aspects of transsexual health. It does not transcend clinical management issues. The gender identity disorders carry a high likelihood of social, psychological, and physical morbidity when unrecognized, unaddressed, treated poorly, and, possibly, even when treated well. Ignoring professional concerns about the current and future mental health of some transgendered persons has its personal dangers for patients (Campo, Nijman, Merckelbach, & Evers, 1993 Campo, J. A., Nijman, H., Merckelbach, H. and Evers, C. 1993. Psychiatric co-morbidity of Gender Identity Disorder: A survey among Dutch psychiatrists. American Journal of Psychiatry, 160: 1332–1336. ). We doubt that the issues facing Martin involved his civil rights. When Case #4, Martin, a 30-year-old health professional student, was seen in follow-up 14 months after his last genital surgery, he was once again in a state of profound depression. His preoperative co-morbidities included polycystic ovary syndrome, dysthymia, two major depressive disorder episodes, and obesity. The first depression emerged after his morbidly obese mother's bariatric surgical death when the patient was aged 16 (father abandoned family shortly after Martin's second birthday). The second followed failing out of college at 20. Prior to surgery, Martin coped with his unhappiness by keeping busy working three jobs. He possessed a natural masculinity which minimized the challenge of passing. He and his therapist thought that he had carefully worked through his religion's position on transgender living. After surgery he had a growing guilt for making the wrong decision. Now miserable with regret, feeling that he let God down, he is contemplating reversion to living as a female, despite his neophallus and masculinized chest. During his interview with the Gender Committee, he could not budge from his rigid view—“I made a profound mistake.”

FOUR PROFESSIONAL CHALLENGES OF WORKING WITH GENDER PATIENTS To Move Beyond the Disorder Among the benefits of working in this arena over many years is the evolution of our understanding of the dynamics of this problem. Studying these patterns of psychopathology can help us to perceive gender transition as a solution—a way out of some form of social, psychological, or developmental paralysis. The dramatic reconstitution of the self after a devastating period of emotional paralysis has been well-described (Storr, 1996 Storr, A. 1996. Feet of clay: Saints, sinners, and madmen: A study of gurus, New York: Simon and Schuster. ). Gender change as a solution asks the professional to frequently reconsider hypotheses about the possibility of an underlying problem. Here is one hypothesis. Male patients commonly express their hope that gender transition will improve their comfort in socially expressing their feelings. They seem to have equated having so many feelings with femininity. It sounds like many of these patients felt themselves to be hopelessly unmasculine because they felt—sad, afraid, dependent, needy, etc. This may be one developmental source of their belief that they possess the soul of a woman. The conviction with which such ideas are uttered is usually jarring for the clinician since it reflects such a limited perspective on the interior subjective life of women. One of these 10 patients told his female therapist that he had a deep appreciation for what it felt like to have menstrual periods. To Understand Professional Assumptions Working with gender patients also allows us to see how our own professional perceptions operate. Our work begins with the belief that GID is a fact of nature. This essential assumption can be challenged by the idea, also supported by data, that diagnoses are arbitrary distinctions that are made for their utility (Zachar & Kendell, 2007 Zachar, P. and Kendell, K. 2007. Psychiatric disorders: A conceptual taxonomy. American Journal of Psychiatry, 164: 557–565. ). Others have cogently articulated views of how people establish and reestablish their identities by selecting and distorting life experiences to fit what they think exists in the universe. It is profoundly jarring to consider that this disorder might not be an irreducible fact of nature but was created by something in modern culture. While at first it may be disconcerting to learn how differently some think about identity (Schrock & Reid, 2006 Schrock, D. P. and Reid, L. L. 2006. Transsexuals' sexual stories. Archives of Sexual Behavior, 35: 75–86. ), these ideas can stimulate our own intellectual growth, make us distrust our certainty, and promote our caution about other people's lives. To Articulate Sources of Professional Avoidance of Patients Numerous private conscious and unconscious forces within professionals limit involvement with patients who consider changing their bodies to match their identities. The deepest ones involve moral (For religious and common sense reasons a person should not do such a thing!) and ethical (Above all do no harm!) forces that generate the first wave of professionals' wariness. When some patients announce “I am a transsexual,” urgently want hormones, and impatiently threaten the doctor to go elsewhere, they unknowingly disrespect the professional. Rather than seeing this as a reflection of the patients' poor social skills, the doctor thinks, “I need this?” Wariness and weariness intensify. Investment in these patients is also difficult because they do not seem to be realistic, psychologically attuned, or trusting, and they don't fit neatly into one diagnostic category. The professional may privately ask, “How am I supposed to think about and work with someone who is naïvely unrealistic?” When the patient persists at looking only to the future of their reborn self, alights only on matters of vanity, and resists discussing family circumstances, weariness intensifies. The professional moves the patient on to what they want and decides to avoid them in the future. “Who needs to battle?” Even in settings specializing in problems of sexuality, there are highly competent professionals who actively avoid dealing with the transgendered. To Keep in Mind the Key Unanswered Question The acknowledgment of psychiatric co-morbidities raises a scientific question. Which psychiatric co-morbidities, if any, bear a relationship to outcome? Professionals should not assume that the question has already been satisfactorily answered. Lacking such high level data, when our Gender Committee makes decisions with a patient, it is often based on hope for a lasting improvement. Some presentations encourage our hope because of their capacity to seamless transition at work and home, to discuss past dilemmas and solutions, current conflicts and use of support from trans community and therapist (Case 7 omitted). It is more difficult to feel optimistic about others. Case #8, Mathew, 32-years-old, unemployed for 5 years, supported by his mother and dwindling inheritance, has failed out of college numerous times. He was fired from his last job. He describes himself as living in fantasy all day when not chatting on the computer to other gamers. Although he aspires to write his own game program, he has made little progress in 5 years. He does no housework to assist his working mother who long ago ceased asking anything of him. He wears female clothing when alone but never out of the house. He secludes himself in his room. His preference for being a girl began at age 5, but his fantasy preoccupation began at age 9 when his parents divorced. He then imagined himself as female jet fighter pilot who saved people. After several years, he chose to live with his father and new wife. He stayed 5 years until they returned him because of his rages. His father was furious when he discovered him dressed in his stepmother's clothes at the age of 14. During this era he began to fantasize himself as a heroine who was raped and tortured. He occasionally comforted himself by the fantasy that he was part of a group of supportive women who cared about him. Despite two minor suicide attempts, this is his first psychiatric care. He still prays daily to God to make him a girl and still is preoccupied with his rape and caring women fantasies. In therapy, he spoke of himself as condemned. He was loquacious but he rambled. He did not respond directly to what the therapist said. He did not seem to have much feeling. He said he never had a friend, which has been the central source of his lingering depression, but had no idea why. He claimed to have sexual feelings, but these were not important to him. He felt shut off but did not know why or from what. He anticipated that transitioning would provide him with nurturing women friends but he refused to go to Transfamily because he only wanted to relate to real women. The gender committee summarized his associated psychopathology as “characterologic,” meaning chronically depressed, passive-dependent, anxious, self-absorbed, hypersensitive to criticism, and limited in his range of affective expression. He is profoundly socially avoidant and pessimistic. “It is too difficult to relate to people.”

SOME ASSOCIATED PATHOLOGIES ARE POLITICALLY CORRECT The issue of co-morbidity is welcomed whenever the facts suggest a sex developmental disorder. Much has been written about the gender variations found among those with intersex conditions (Diamond & Watson, 2004 Diamond, M. and Watson, L. A. 2004. Androgen insensitivity syndrome and Klinefelter's syndrome: Sex and gender considerations. Child and Adolescent Clinics of North America, 13: 623–640. ; Meyer-Bahlburg, 2005 Meyer-Bahlburg, H. F. L. 2005. Introduction: Gender dysphoria and gender change in persons with intersexuality. Archives of Sexual Behavior, 34: 371–373. ). In these diverse states, political activism has empowered more patients to make their own minds up about their genital fates and gender roles (Hughes, Houk, Ahmed, & Lee, 2006 Hughes, I. A., Houk, C., Ahmed, S. F. and Lee, P. A. 2006. Consensus statement on management of intersex disorders. Archives of Disease in Childhood, 91: 554–563. ). There has always been much less public and professional resistance to dealing with children or adolescents whose sex development is amiss than those far more prevalent patients with GID with normal genitalia (Meyer-Bahlburg, 2007 Meyer-Bahlburg, H. F. L. 2007. Variants of gender differentiation in somatic disorders of sex. International Journal of Sexual Health, in press). Other medical disorders, such as obesity, thromboembolic phenomena, juvenile diabetes, epilepsy, mental retardation, malignant hypertension, etc. are also freely accepted co-morbidities since they may impact on the management of individual patients. A recent excellent review of sex developmental disorders presented a differential diagnosis of GID in adults and failed to conceptualize that these ruled out disorders can be co-morbid (Bostwick & Martin, 2007 Bostwick, J. M. and Martin, K. A. 2007. A man's brain in an ambiguous body: A case of mistaken gender identity. American Journal of Psychiatry, 164: 1499–1505. ).

THE INVISIBLE In our gender clinic, we only occasionally encounter a new patient who does not seem to have much amiss with his life beside GID. The literature of gender identity disorders provides almost no guidelines for the management of those with associated psychopathology (Burns, Farrell, & Brown, 1990 Burns, A., Farrell, M. and Brown, J. C. 1990. Clinical features of patients attending a gender identity clinic. British Journal of Psychiatry, 157: 265–268. ). There is great faith in the value of hormones, real life test, and surgery (Pfafflin & Junge, 1992 Pfafflin, F. and Junge, A. 1992. Sex reassignment: Thirty years of international follow-up studies: A comprehensive review. International Journal of Transgenderism, : 149–457. ). The fate of people with GID who do not transition is not known. While there is not much faith that psychotherapy profoundly improves the gender disorders, they are known to remit (Marks, Green, & Mataix-Cots, 2000 Marks, I., Green, R. and Mataix-Cots, D. 2000. Adult Gender Identity can remit. Comprehensive Psychiatry, 41: 273–275. ) The fate of the majority of adult patients who have had sex reassignment surgery is invisible in the literature (Carroll, 1999 Carroll, R. A. 1999. Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy, 24: 128–136. ; Lawrence, 2006 Lawrence, A. A. 2006. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Archives of Sexual Behavior, 35: 717–728. ; Pfafflin & Junge, 1992 Pfafflin, F. and Junge, A. 1992. Sex reassignment: Thirty years of international follow-up studies: A comprehensive review. International Journal of Transgenderism, : 149–457. ). They are lost to follow-up as was Reed for years. Case #9, Reed, now 53, a musician with GID, dysthymia, and panic disorder, was abruptly divorced in 1987 by his depressed wife when he refused to have a child. Three years later she was diagnosed with schizophrenia. In 1996 he transitioned to living as a woman with our endocrine support. When approved for surgery in 2004, she was supporting herself as a beauty consultant and was active in the transgender community. She partnered with an unreliable unpredictable disabled bipolar man who abruptly left her without explanation. She came to be disenchanted with the transgendered community and left her second career when laser technology was introduced. Shortly after the loss of her male partner as her business was failing, she sold her condominium for income. Her urologist, who was treating her for chronic prostatitis, gave her alprazolam for stress. She resumed psychiatric care and obtained a separate alprazolam prescription without informing the psychiatrist that she was already taking the drug. As she sought to establish herself in a new career, her alprazolam abuse became apparent. She had a withdrawal seizure when her psychiatrist tapered her dose in 2006. When she recovered, she discontinued female hormones, returned full time to the male role, and moved in with his parents. Reed remained psychiatrically stable while he endured unemployment and lived off the proceeds of his condominium sale. Reed is now employed 25 hours/week. He no longer aspires to a sexual relationship with anyone. Less than ideal outcomes to transition, hormones, or surgery should not be surprising. Mention of them has appeared in the literature for decades (Levine, 1984 Levine, S. B. 1984. Follow-up on increasingly Ruth. Archives of Sexual Behavior, : 287–289. ; Walinder & Thuwe, 1975 Walinder, J. and Thuwe, I. 1975. A socio-psychiatric follow-up of 24 sex-reassigned transsexuals, Copenhagen: Scandanavian University Books. ; Olsson & Moller, 2006 Olsson, S. E. and Moller, A. 2006. Regret after sex reassignment surgery in a male-to-female transsexual: a long-term follow-up. Archives of Sexual Behavior, 35: 501–506. ). One brighter spot in this story is emerging in Holland among adolescents with GID. Carefully screened for the absence of associated psychopathology, all patients have been carefully supported before, during, and after their transitions, and are doing well (Smith et al., 2001 Smith, Y. L. S., vanGoozen, S. H. M. and Cohen-Kettiis, P. 2001. Adolescents with Gender Identity Disorder who were accepted or rejected for sex reassignment surgery: A prospective follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry, 40: 472–481. ). Their care is a far cry from that received by most transgendered adults. Since the inception of our work in 1975, it has been difficult to follow up on our adult patients. Two individuals among this sample of 10 were lost to follow-up and resurfaced when they were experiencing significant psychiatric difficulties. Case 10, who refused to be presented, was intended to illustrate how difficult it is to keep contact with patients.