Money & Ehrhardt, 1970
The Johns Hopkins University School of Medicine, Baltimore, MD, USA

The data of this follow-up study was presented for the first time at the 10th Scientific Meeting of the German Society for Sexual Research, June 1969 in Berlin. After the publication of Benjamin (1964b) and Walser (1968), it was the third follow-up study published in the German language that corresponds to our criteria. As in Benjamin, it treats patients from the USA. Patients with transsexual symptoms have been treated and guided by Money in the Psychohormonal Research Unit of the Johns Hopkins University Hospital since 1952. The patients were operated in private clinics mostly outside the USA. The Johns Hopkins University Hospital was the first clinic in the USA to have named a Gender Identity Committee and has performed since 1965 surgical gender reassignment, sending a signal that was followed fast by many other university clinics in the USA and in Canada.

• Sample
• Study Methods
• Results
• Evaluation Fields and Criteria
• Authors' Conclusion
• Indication Recommendations
• Remarks

Study Methods
The authors participated in the treatment and indications for hormonal and surgical procedures. The follow- up study seems to be limited to the evaluation of patient files (one of the patients was last seen seven years before the follow-up study, comp. p. 75).

Evaluation Fields and Criteria
The authors chose evaluation criteria that were very objectizable and independent from the interpretation of the researcher. Evaluated were the time periods of partnerships (marriage), professional activity, criminal convictions, psychiatric treatment and a subjective evaluation of the gender change.

Results
Females: Seven females lived following surgery in lasting partnerships, resp., marriages that lasted between two and five years. Two had been separated after two or more years. Professionally nine had bettered themselves; eight had no change. No female had worsened professionally. Four females had criminal convictions before surgery and two of these four also after surgery. All six convictions were for disturbance of public order due to transvestism; in two cases additionally for property crimes. The post-surgical arrests were in situations in which the patients were taken for males in female dress and because they could not demonstrate that they had made a sex change with medical help. Post-surgically there were no convictions. Psychiatric and psychotherapeutic help was needed by eight females before surgery. After surgery only one needed it. Contacts that were in immediate relation to the sex reassignment and necessary help are not included. As subjective evaluation all 17 females said that they would take upon them the surgical and hormonal procedures again if necessary. None of the females regretted the sex change which was thought of as very noteworthy by the authors because some of the patients required multiple corrective surgery and some were still not able to have satisfactory sexual intercourse.

Males: Four had post-surgically a partnership or marriage of at least three years. None of them was divorced. Three lived alone. Professionally three had bettered themselves. With four the professional situation was unchanged. Criminal convictions happened neither pre- nor post-surgically. Psychiatric help was needed pre-surgically by three patients, post-surgically by one. This one had, circumventing the Psychohormonal Research Unit, done all procedures including a penis operation somewhere else with bad results.

Evaluation Fields and Criteria
One FMT who circumvented the Psychohormonal Research Unit for treatment lived after that alternating between male and female. He attempted suicide twice. The authors attributed these suicide attempts to three factors: Besides the unsuccessful surgery, the untreated climacterium as well as the problematic relations to the partner played a decisive role.

Authors' Conclusion
The authors called the results provisional and the criteria that they had chosen for the success control as being "to what extent the living conditions of male and female transsexuals change after the sex-reassignment" (p. 85). Summarizing, they say that "psychological, hormonal and surgical means ... (have) a demonstrable, encouraging and improving effect on the previously conflicting life situation of the patients " (p. 86). They attributed the positive results partially to the selection criteria of the Gender Identity Clinic of the Johns Hopkins University Hospital.

Indication Recommendations
The Gender Identity Clinic had established eight main selection criteria for admittance to the treatment program, resp., for the indication for surgery: Being of legal age; American citizenship; living near the clinic; close person of reference who supports the treatment; unmarried; if possible, no criminal record. The most important criterion was that the patient had lived at least one or two years before surgery in the desired gender role and had provided a livelihood. Finally, patients with psychoses or seizures were not accepted. The authors recommend a restriction in establishing the indication and to observe the selection criteria, especially the long-term testing of the other gender role.

Remarks
This research, that does not consider any previous follow-up researches, seems to be very simple in its design, especially in regard to the scope that it intends to research, that is, "to what extent the living conditions of male and female transsexuals change after the sex-reassignment" and the result that "psychological, hormonal and surgical means ... (have) a demonstrable, encouraging and improving effect on the previously conflicting life situation of the patients." (p. 72). The mentioned psychological treatment measures were not explained in detail.

The conclusion that "for almost all transsexuals, male or female, the adaptation of the new gender role coincides with the hormonal reassignment and therefore is long before the surgical gender reassignment" (p. 75) is notable. One of the FMTs was already partially operated (hysterectomy) but still lived as a female, so that it is allowed to ask if the authors observed the indication criteria that they themselves demanded.