Randell, 1969
Dept. of Psychological Medicine, Charing Cross Hospital, London, UK

This follow-up study was the first bigger European study that reached importance, especially because it was included in the book published by Green & Money (1969), Transsexualism and Sex Reassignment , published in the USA. It thus collaborated that sex reassignment surgery was accepted in the USA as treatment for patients with gender identity disorders.

• Sample
• Study Methods
• Evaluation Fields and Criteria
• Results
• Case Studies
• Suicide Attempts/Role Re-reversal
• Follow-up Studies Mentioned
• Authors' Conclusion
• Indication Recommendations
• Remarks

Study Methods
The author participated in treatment and indication for surgery of 21 of the 29 females. In some cases he got a second psychiatric opinion. The follow-up study is based on clinical interviews (including physical examinations) and regards the subjective opinions of the patients and the conclusion of the author.

Evaluation Fields and Criteria
Evaluated were the psycho-social adjustment, the cosmetic surgery results and the ability to function sexually. In how far the evaluation criteria were used pre- and post-surgically or only post-surgically cannot be read in the publication. The evaluation criteria were only defined for females, not for males.

The psycho-social adjustment was evaluated in the following steps: "'Poor' adjustment: The subject was in conflict with his environment, distressed and often showing active anxiety and depressive patterns. Depression was often severe, and suicidal thoughts were present or suicidal attempts had been made. The subject was usually unemployed and relations with family and the immediate social environment were poor. The situation produced tension and distress. 'Fair' adjustment: The subject had come to terms with his environment to some extent, was supported by his relations and friends, and accepted by society as a female, although the individual himself was still overconscious of his basic male status. Some men in this category were employed and self-supporting. 'Good' adjustment: The subject in this grade was usually confident and comfortable in the female gender role, had established good relations with society in that role, and was accepted by family and friends as a woman. Almost without exception they were employed and/or living quietly as "wives" to male partners with whom a fairly satisfactory sexual relationship had been established. They were accepted as females, but they desired operation so that they could enjoy greater security, freedom from detection as passed males, and a more complete sense of identity as females. 'Excellent' adjustment: Transsexuals in this category felt that they had achieved female sexual status in the eyes of the world; they felt that their body conformed more or less to the female phenotype. Sexual relations using an artificial surgically constructed vagina was an ideal desired by some of then, while other patients who had only simple castration and penectomy were in this category because their assimilation into the female gender role was so adequate that their social adjustment was excellent. In some cases, sexual self-expression was not valued highly or other forms of intercourse were employed to meet the demands of the partner. The transsexual was then content to share his life with a male companion or enjoy complete acceptance as a woman by society" (Randell, 1969, p. 369).

The cosmetic and functional surgical results were evaluated as: very poor, poor or fair if only a penectomy was done and as good if a vaginoplasty had been performed.

Results
Females: Cosmetic: Surgical results were evaluated by the author to be ten times as good, 16 times as fair and twice as poor. Subjectively, four females were very satisfied with the cosmetic results, 18 satisfied and six dissatisfied. In comparing the self with external evaluation it is noticeable that the surgical results are rated better by the author than by the patients themselves.

Regarding sexual functioning ability, it was discovered that 19 of the 29 females could not have sexual intercourse because of unsatisfactory surgical results. Satisfaction, resp., dissatisfaction with the sex change did not depend on sexual functioning in the author's opinion.

The post-surgical adaptation was evaluated seven times as excellent, 14 times as being good, three times as fair, once as poor and four times as very poor. Pre-surgically, more than one third of the patients were evaluated regarding their adaptation as poor and onethird as fair. A worsening in comparison to the pre-surgical status happened to four patients.

Males: The functional results of the phalloplasty could not be evaluated for one male because the surgery was not yet finished. The other one was able to urinate standing. The cosmetic results of breast reductions were evaluated five times as being good and once as fair (because of scarred and wrinkled tissue). Subjectively five males were satisfied with the results of the mastectomy and one male was dissatisfied despite the result of surgery being good in accordance of the opinion of the author. The social adaptation was evaluated for three males as excellent, for two as good and for one as being fair.

Case Studies
Many clinical impressions are reflected, but the development of a single patient cannot be reconstructed by them.

Suicide Attempts/Role Re-reversal
Six patients had attempted suicide pre-surgically. Post-surgically two females committed suicide - about whom the author indicates that besides transsexualism, additional psychiatric factors had contributed. He highlights that he did not participate in the surgical indication for these two. After the author had denied treatment to these two patients, they succeeded in obtaining referrals for surgery from another psychiatrist.

One female was dissatisfied with the surgical results and lived at the time of the follow-up study again as a male.

Follow-up Studies Mentioned
Benjamin, 1964a, 1966; Hertz et al., 1961

Authors' Conclusion
"The postoperative results reported above indicate that the majority of males and females undergoing operation for sex reassignment are subjectively and objectively improved both in their adjustment to their environment and in their own feelings of well-being and satisfaction in their gender role" (p. 379). For people who, disregarding their suffering by the discrepancy between sex and gender identity, are normal, he considers sex reassignment as indicated and justifiable. "The improved psychological adjustment of these individuals after operation bears striking witness to the efficacy of sex-reassignment surgery. It seems that a majority of those undergoing such operative intervention are, in the end, content with their status. Certainly there is often massive relief of mental suffering and discontent, with an increased incentive for living and working which can make these socially disabled individuals contributory, worthwhile citizens" (p. 380). Further evaluations of the author are cited below in the remarks.

Indication Recommendations
A sex reassignment surgery is deemed by the author as justifiable for patients who are mentally, psychologically and socially stable. Psychopathies and suicidal threats of patients are contra-indications according to his viewpoint. It is also to be regarded how long a patient has lived in the other gender role prior to surgery, if the patient could earn a living, was socially inconspicuous and if the patient finds one's way better in the other gender role after the role change. Deviating from this, two females had never worn female clothing before, that is, they had evidently not fulfilled the indication criteria demanded by the author.

Remarks
The publication is outstanding because of its explicit description of the pre-surgical situation of the researched sample. From a methodical viewpoint, it has to be noted, however, that one cannot speak of a standardized evaluation procedure because neither the time point of the evaluation is indicated nor are the evaluation criteria precisely defined. In the scale for the evaluation of the adjustment and in the text, for example, the adjustment is characterized as social and in other parts as psychological.

Remarkable is the attitude of the author - who tried to answer if sex reassignment surgery is justifiable or not. His conclusions demonstrate that he affirms this question. But he leaves no doubt in that he would deny to recognize the operated transsexual post-surgically as females or males as which they now live. For him, transsexualism is a severe psychiatric illness that is diminished by the treatment procedure. For the individual person a better adjustment to the desired gender role is made possible, nothing more. For most of them, this has a considerable psychological and social relief as a consequence. If transsexuals try to change their birth certificates after surgery, the author considers this is as an "untenable request, ... for I do not subscribe to the opinion that a phenotypic male can have a female psyche. Those who profess to have such mental orientations are, in fact, anatomical males with obsessional beliefs or over-valued ideas that they are female, and therefore psychiatrically abnormal. If they have passed into the female gender role it seems reasonable to recognize their social status by the issue of employment cards, driving licences, passports in a female status, but it is not possible to certify that they were wrongly described as male at birth, unless they are anatomically pseudohermaphrodites. Only on such grounds can birth certificates be emended." (pp. 367-368). "The removal of the visible anatomical structures which reflect basic masculinity is seen as the final step into true femininity. Only a minority accept it for what it really is - that is, a neutering procedure or, perhaps more correctly, a castrating process. It is difficult to persuade transsexuals who have had their genitals removed that they are, in fact, nothing more than castrated males, although they may give lip service to this concept if pressed. Because of their often consciously fostered orientation they compel themselves to believe that they are at last women. ... By castration the transsexual patients have achieved, to a limited degree, a harmony of mind and external conformation which they assert will entitle them to take on the full privileges and functions of a female in society. In fact, they fall short of full function as a female for obvious reasons related to coition and reproduction - regardless of how they may attempt to convince themselves that they are female." (p. 375). "Following operation, threre was a tendency to further self-deception over sexual status, and at least 19 regarded themselves as having achieved the female sexual status." (pp. 375-376). "They have to believe that their sufferings have been worthwhile and have ended in success." (p. 376).