Benjamin, 1964b
Private Practice, New York, NY, USA

This is the first follow-up study with more than five operated patients published in the German language. This publication is almost identical with Benjamin, 1964a except that the sample is bigger. Evidently the author is impressed, not to say enthusiastic, about the positive developments that he observed post-surgically in his patients.

• Sample
• Study Methods
• Evaluation Fields and Criteria
• Results
• Case Studies
• Suicide Attempts
• Follow-up Studies Mentioned
• Authors' Conclusion

*The author says that the total group was 200 transvestites whom he had seen in the previous 13 years. Among these 200, 125 were transsexuals (see corresponding remarks in Benjamin, 1964a).

Study Methods
The author is the only researcher and participated partially in making the indication. The indications for the study methods are imprecise: "These 44 patients could be -- with one exception-- examined or followed up by me, so that the katamnesis was known approximately, mostly through personal consultation, or otherwise by correspondence or messages from relatives and friends " (p. 500).

Evaluation Fields and Criteria
The overall shape, appearance, sexual functioning and (one's) position in society (marriage or profession) were evaluated. The evaluation criteria are mentioned vaguely: The results of females were thought to be excellent if they were in all four above-mentioned areas "satisfied, partially happy and successful" (p. 500). They were termed satisfactory if the female did not adapt fully to her role and profession/marriage, but did not regret the operation. Generally they were very satisfied, but had problems with sexual intercourse because the "artificial vagina" (p. 500) either closed, was too narrow or too short or contained bothersome scar tissue. In many cases, according to the author's opinion, follow-up corrections by surgery could have been done which could lead to a new classification as excellent.

Results
Overall the author judged the results of 16 females as excellent and of 24 females as satisfactory. With two females (one of them had a fistula) the conclusion was doubtful because the author did not have sufficient information. The situation of a 64-year-old female who was operated at age 56 (penectomy and orchidectomy ; no vaginoplasty), was classified as unsatisfactory. She could not maintain the previously high living standard and regretted the procedure. Even though the capacity for orgasms was not an evaluation criterion because of the presumed unreliability of the information the author estimates that about half of the females "experience a certain type of orgasm during sexual intercourse" (p. 500). " All patients state, disregarding that one exception, verbally or in letters, that they are unconditionally happier than at any time before surgery, immaterial if they had lived before as a male or (illegally) as a female"(p. 500).

Case Studies
The publication is filled with short case studies that are frequently imprecise. For example, the author indicates that a patient died five years after the "operation (without castration)" (p. 500) of a heart attack. It is not clear what was meant by this surgery.

Suicide Attempts
A 20-year-old female "developed an addiction to morphine during her career as prostitute" (p. 500). She died three years after surgery of an overdose, while it remained unclear if it was a suicide.

Follow-up Studies Mentioned
Hamburger et al., 1953

Authors' Conclusion
"In conclusion, I can only highlight that -- as far as my experience goes (as a sexologist, not a surgeon or psychiatrist) -- it is at all possible to provide an unhappy transsexual male a happier future as a female by surgical means or hormone treatment. Even though the observation time is not very long and the necessity of a larger amount of clinical material is evident, the reported results are sufficient to abolish the fundamentalist opposition to the endocrinological and surgical treatment of transsexualism" (p. 500). To the contrary of other authors, Benjamin does not think that prostitution and promiscuity of his patients is negative: "Sexual promiscuity or prostitution is probable in 17 cases. Both have a great attraction for these patients because their femininity is again and again affirmed by them" (p. 500).