Data derived from a 4-month hospitalization and 18-month follow-up of an adult male transsexual is presented. His mother, an embittered, empty woman, kept her child in constant and excessive physical contact with her. She sabotaged all of his efforts at separating from her and achieving a sense of masculinity. His father, effeminized by his own mother, was unconcerned with his son's rearing except for infrequent rages at the mother-child closeness. The patient became an effeminized boy, perpetuating early forms of identification with his mother and unable to effect the normal identification with his father. The authors outline the subsequent tenuous and fragile development of the patient's gender identity through homosexual, transvestic, and heterosexual phases. They discuss his increasing feminine sense of self with its ultimate fragmentation to primitive forms of both “as if” role playing and “fusions of self and object,” which led to the transsexual resolution and operation. The role of aggression in the transsexual resolution is discussed; serious postoperative complications are noted.