Pre-surgery diagnostic procedures, in which psychiatric examination takes a major role, have long-lasting consequences. Through the case presentation of a diagnostically and therapeutically interesting gender dysphoric individual, the authors wish to address the necessity of continual follow up of transgerder persons even after recommendation letter for surgery. the authors in this paper give detailed data on gender history and gender transition for the 49-year-old divorced biological female with university education who lives alone. Gender transition was very slow according to his own capacities for acceptance of change. He had hystory of mild depressive non psychotic episodes periodically and severe suicid attempt at 12. in his 48 he was clinically significant depressed after metoidioplastic surgery. Afterwards he gradually developed paranoid symptomatology which progressed to psychotic level after antidepressants. Inspite discontinuation of medication paranoid features additionaly escalate. He is still preoccupated with genital complaints which has character of cognitive distorsions and at the moment not motivated for further genital transition (phalloplasty).

Gender history, clinical presentation and successful living full-time as a male for thirty years confirms that presented patient meets all criteria for the Gender Identity Disorder. This case report reminds us to pay attention to some precautions and possible risk factors for reconstructive surgery reccomendation, such as:

1. 1. Personality traits (depressive, paranoid, avoidant).

2. 2. Former psychiatric disorder (depression, suicidal behaviors, transient psychotic features).

3. 3. Slow transition in full expression of gender identity (important predictor of possible psychotic relapse in this case).