To the Editor: Our article is mainly criticized for the limitations inherent to surveys, already pointed out by us (p. 1334). For instance, Dr. Giltay et al. rephrase our point that patients may have been counted more than once by the different respondents, whereas we noted that duplications cannot be ruled out since "some patients may have been treated by more than one of the responding psychiatrists" (p. 1334). They also share our thoughts with their critique that "patients with psychiatric disorders will be most likely to consult a psychiatrist." In the article, we wrote, "Psychiatrists probably see a self-selected group of patients with cross-gender confusion (those with psychiatric problems would be more likely to visit a psychiatrist)" (p. 1334).

After rephrasing several obvious limitations and claiming that their gender clinic treats "over 95% of the Dutch gender-dysphoric patients," they judge the number of 584 patients reported by our respondents to be unrealistically high, "unless proven otherwise." However, our results strongly suggest that their claim that their clinic treats over 95% of gender-dysphoric patients is unrealistic. The results from our survey do not leave much room to doubt that many Dutch psychiatrists are cautious in referring patients to specialized gender clinics. Only 12.5% of the 584 gender-dysphoric patients we reported on were indeed referred to such a specialized gender clinic by the responding psychiatrist. Without being asked specifically for this information, psychiatrists wrote on the survey forms that they would "never advise this treatment route," and their quantitative reports on the closed questions underline this. Other psychiatrists spontaneously reported on alternative treatments that they recommend and use (psychotherapy, psychopharmacological treatment, etc.). Simply on the basis of the experiences reported, it is likely that there may be a substantial group of patients with gender dysphoria who are not referred to investigate the options of undergoing hormonal and surgical sex reassignment. Furthermore, we would like to point out that 584 cases spread over 186 respondents with an average working experience of 14 years means that Dutch psychiatrists are consulted by a patient suffering from gender dysphoria every 4.5 years. Judged from our own psychiatric hospital experience, this figure is far from unrealistically high.

Our study was not designed to be representative of the "whole population of transsexuals," as Dr. Giltay et al. suggest, and likewise, the group of patients at the specialized gender clinic are not representative of all "Dutch gender-dysphoric patients," as they claim. The goal of our study was to learn more about the opinions and experiences with gender identity disorder in a substantial group of randomly selected Dutch psychiatrists. Since both a relatively large overlap between gender identity disorder and other psychiatric disorders was being reported by them, and dramatic misdiagnoses can occur (e.g., reference 1), we feel that addressing issues about how other psychiatric disorders are to be ruled out, as well as an open debate about the appropriate minimal starting age for sex reassignment therapy, is warranted.

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