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Gender identity disorders (GID) in young people are complex and often distressing conditions. The paper starts by examining the experience of the professional worker resulting from the interaction with this group of young people and their families. This is frequently characterised by a sense of being under pressure and in danger. The view put forward is that the position of professionals often mirrors the mental state of these young people, which is described by the metaphor ‘working at the edge’. The issue of how to move to a position of safety for the young person and the professional is addressed. The paper describes a developmental model of care based on psychodynamic understanding, and distinguishes between conditions that are transient and conditions that persist during the course of development. Possible factors involved in the persistence of the ‘atypical gender identity organisation’ are considered based on Baron-Cohen's concepts of systemising and empathising. The therapeutic aims in working with these young people are revisited 10 years on from the first publication. Two contrasting cases are used to illustrate the persistence or desistence of the GID in the course of development. The paper concludes that while there is a tendency to move to provide hormonal interventions early for adolescents who are considered not amenable to change in their atypical gender identity, the integration of psychological, social and, when appropriate, hormonal interventions remains central to the provision of good standards of care.