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Sam, an only child, was 4 years, 2 months of age at the time of our first meeting. He was attending a full day nursery program. His parents sought psychiatric help for him because, as they put it, “He wants to be a girl.”
For as long as they could remember, Sam enjoyed what his parents called “dressing up.” Mother dated the onset of this behavior to the time just after her father died, when Sam was 18 months old. At that time he began to put on necklaces and wrap towels around himself as “skirts.” For a while the parents tolerated this, but father was uncomfortable with it because he had “questions about [his] own sexual identity.” Then Sam began to verbalize a desire to be a girl. Mother had forbidden his putting on her clothing, shoes, or jewelry, but his favorite activity at nursery school remained dressing up as a woman.
Sam was described by his parents as a difficult child and, particularly when he was with them, extremely negative and ornery. A phase of biting and spitting had just ended. On the other hand, they thought that he was rather clever and verbal, and sometimes treated him as if he were older. He had a vivid imagination and a “heavy involvement” in fairy tales. He would often become obsessed with, and at the same time frightened by, a story in which the wicked character was a woman. He had entered nursery school when he was three. Although well liked by his teachers, he did not relate so well to his peers. In