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Experience with more than 500 patients over the last decade has led to the conclusion that the quest for sex reassignment is a symptomatic compromise formation serving defensive and expressive functions. The symptoms are the outgrowth of developmental trauma affecting body ego and archaic sense of self and caused by peculiar symbiotic and separation-individuation phase relationships. The child exists in the pathogenic (and reparative) maternal fantasy in order to repair her body image and to demonstrate the interconvertability of the sexes.
Gender identity exists not as a primary phenomenon, but in a sense as a tertiary one. There is, no doubt, a tendency to gender-differentiate in a way concordant with biological endowment. Nevertheless, gender formation is seriously compromised by earlier psychological difficulty. Gender identity is a fundamental acquisition in the developing personality, but it is part of a hierarchical series beginning with archaic body ego, early body image, and primitive selfness, representing their extension into sexual and reproductive spheres.