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The findings of this paper are based on a 3-year study at the Gender Identity Clinic of University Hospitals of Cleveland, involving 16 patients who were sexually revised (SR) from a total of 125 applicants. Three of these patients were provided second-stage surgeries which were begun elsewhere. The paper addresses some of the major problems of the SR patients' pre- and postsurgical experience. Specifically, a) evidence is provided to suggest the existence of a well defined preoperative syndrome which often affects the postoperative course of recovery which may lead to a clinical state of depression; b) the problems and process of the medical team in the treatment of the SR patient are discussed; and c) a modified version of Janis' counseling model for the high risk presurgical patient (to be employed with the preoperative SR patient) is introduced. These important but often neglected topics help us to understand some of the psychiatric management problems in the pre- and postoperative SR patient, while also pointing to some of the difficulties researchers have had in providing follow-up studies with this patient population.