Hastings, 1974
Dept. of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA

This follow-up study stems from one of the first and most renowned gender identity clinics in the United States, whose establishment was even published in Lancet (Hastings & Blum, 1967). The follow-up studies by Kando (1973) and Hastings & Markland (1978) are from the same research and treatment project. The latter mentioned publication is almost identical with this one, except that there the two case studies of patients that were not included in the statistics are omitted.

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

Study Methods
The follow-up study was done at two times: Immediately after surgery, clinical impressions were recorded and about five years after surgery a semi-standardized follow-up study was done.

Evaluation Fields and Criteria
Immediately post-surgically, it was evaluated how the patient reacted to the procedure. The author was interested in four questions by which he took data systematically: Was there a mourning reaction because of the loss of genitals? Was there phantom pain? Did a psychosis happen after surgery? Was there a demand for other procedures (breast augmentation, Adam's apple reduction) immediately post-surgically ?
Five years post-surgically, the economic, sexual, social and mental constitution of the females were evaluated on a four-step scale each. The scales were defined as follows (pp. 337-339):

Results
For the time immediately post-surgically the following results are shared: (1) all patients were post-surgically very relieved that surgery was done and did not have phantom pain; (2) In the first days following surgery some patients asked if further procedures were possible; (3) No patient was psychotic immediately post-surgically; (4) There was no mourning reaction about the loss of the penis and testes.
Long-term post-surgically in accordance to the above-mentioned criteria in the category economics the situation of 11 females was characterized as excellent, for three as good, for three as fair and for eight as being a failure. In the sexual category the results are classified for ten as being excellent, four as good, two as fair and nine as failures. The bad results are, according to the opinion of the author, in direct relationship to the poor quality of surgical outcomes. Frequently corrective surgery was necessary, which partially did not have success either. In the social area the results are evaluated for six as excellent, for eight as good, for three as fair and for eight as failures. Those females who are not adapted socially were, according to the indications of the author, already pre-surgically "sociopaths."

Case Studies
For each patient there are annotated short commentaries. Further, there are two case studies of patients who were not included in the follow-up study (see below).

Suicide Attempts/Role Re-reversal
By subjective evaluation by the females, about every second one was saved from suicide by surgery. "Most" (p. 335), had attempted suicide before surgery. Three females made, mostly in connection with a partnership crisis, post-surgical suicide attempts - one of them three times.
One patient with an unstable history with a long-year jail term and alcohol dependency cut his penis off with a razor blade at age 35. Only after this was he accepted by treatment by the author, who wanted to observe him for a longer time. The patient was then again admitted stationarily in a psychiatric institution because he had also cut off his testes and wanted to force a vaginoplasty by a threat of suicide. With this threat, he finally had success. Post-surgically this patient developed a paranoid psychosis. Later on he lived as a male and stabilized himself by it.
The second patient was a 22-year-old male with a typical transsexual history. He was started in the year 1967 on an estrogen treatment and was supposed to be operated the following year. He stopped the operation on short notice, had a religious conversion and abandoned the desire for sex reassignment.

Authors' Conclusion
"The general success rate of personal satisfaction on the part of most patients has averaged good. Not excellent, but good" (p. 344). The author considers surgical sex reassignment as the best that presently can be offered. "Nothing else holds promise. Granted that the surgical route is difficult and clearly second-best to a method of preventing these tragic reversals of gender identity and role, yet it seems to be all that there is to offer at present" (p. 344). The author evaluates his results cautiously in the regard of a generalization. The case number is too small to present a really scientifically secure result. About the possible accusation that the results would be distorted because the author and treatment provider were identical, he said, "I have compensated for bias by being overly harsh on the ratings of patients. Where bias and error have crept in, I think it credible to state that the error tends to be on the pessimistic side." (pp. 343-344).

Remarks
The research is important because, for the first time, even though they are vague, valuing scales to evaluate the post-surgical situation were defined. These first scales became the model for all later follow-up studies insofar as they used valuing scales. The research shows how scientifically -- but also how naively -- the problem of transsexualism was worked on. When the first patient with transsexual symptoms came to the clinic in 1964, a long-term research project was established with the perspective of a follow-up study after ten years and this was immediately publicized. The number of inquiries of (potential) patients increased so that -- mostly formal -- limitations to admittance had to be introduced. The paper discussed here reflects the results at half-time of the project. Exact figures about how many patients were actually accepted into the program (in reality) are not reflected.
From the beginning the problem of control groups was recognized and discussed. The attempt to use a waiting group as a control group was deemed not realizable because the patients went to other treatment centers. With the planned long follow-up periods of ten years, it could not be expected from any patient to wait so long. At least the research by Kando (1973) was attached to the project.
It is notable how little content questions are analyzed in the much-announced scientific project (Hastings & Blum, 1967), such as, for example, the differential diagnosis or the type of psychiatric, resp., psychotherapeutic treatment. It is almost not to be learned that patients with psychoses were not admitted. Of what the treatment consisted in between the initial psychiatric examination and the surgery, resp., between surgery and follow-up study, is not mentioned. It can also not be discerned if it was expected of a patient to live in the required gender role, or for how long, before starting somatic interventions.
Questionable -- and even viewed critically later on by the author -- was an experimental intent in the project that spurted the appearance as if differential diagnostic thoughts were used rather carelessly: "One member of the Gender Committee had had a long-term interest in sociopathy and was curious to see if high estrogen dosage and surgery might alter the condition for the better. If there is one follow-up conclusion that can be made with assurance at this stage, it is that estrogens and sex reassignment surgery do not alter the sociopath transsexual. He is as sociopathic five years after surgery as he was before it" (p. 336).
The proposition to take digital prints from all patients to check throughout the country if they had not committed a crime at some time seems to be odd. With such an uncommon measure in the frame of a medical treatment, one has to ask the question if there are not other motives than those used to justify it. The motive that somebody could try to evade persecution by law by means of a sex reassignment surgery seems to be very far-fetched and far from any clinical reality. This is why it should be questioned if it wasn't a projective defense mechanism of the project workers who spurted this to keep the fear in check that they were breaking laws by the treatment offer.
Finally, the publication contains a remark that is to be heard in many variations in the literature about transsexualism and even more frequently with dialogues with medical professionals and psychologists who work with the problem of transsexualism: "The psychopathic, manipulative, demanding transsexual patient is the one who may occasionally cause the surgeon and psychiatrist to wish that they had never become involved with a transsexual program" (p. 338). We will talk about this theme in the final chapter.