Laub & Fisk, 1974
Dept. of Surgery, Stanford University School of Medicine, Stanford, CA, USA

This work group at Stanford worked diagnostically with the guidance term Gender Dysphoria Syndrome(Fisk, 1973), in which they compiled: (1) classic transsexuals; (2) selected effeminate homosexuals; (3) transvestites; (4) patients with psychotic mistake of their sexual identity; (5) neurotic patients who tended toward impulsive actions on their genitals; (6) socio- and psychopaths. Patients of the first three diagnostic sub-groups who went to consult the team for a sex reassignment were divided into three categories - depending on how far they were ready for the surgical procedure, resp., how the prognosis was evaluated. The treatment program was conceived with the goal to answer the question "Is surgery worthwhile as a method to improve the quality of life in certain patients with Gender Dysphoria Syndrome?" (p. 391). The sample described here is the same as described in Gandy (1973).

• Sample
• Type of Treatment
• Evaluation Fields and Criteria
• Results
• Follow-up Studies Mentioned
• Authors' Conclusion
• Indication Recommendations
• Remarks

Type of Treatment
Patients were divided into three categories: Category A fulfilled already at the time of the first presentation "all requirements for surgery" ; Category B included all patients who "potentially could fulfill all the requirements, but who lacked time in their therapeutic gender test (or who lacked certain accomplishments, such as steady employment or passing grades in school).; Category C included "those not qualifying" (p. 391) for a gender reassignment.
It was expected in patients of category A that they were successful in social, psychological, sexual and professional areas; lived and worked one to three years without limitations in the other gender role; were treated with hormones; were not psychotic; did not have mentionable sociopathic aspects (jail terms or drug dependency); were not married; were at least 21 and not older than 58 years and did not suffer illnesses that reduced the live expectancy (for example, high blood pressure, diabetes).
Patients of category B could move into category A if they successfully made use of the offerings of the treatment program. These consisted of professional counseling; cross-training through the labor office; cosmetic counseling; body building for FMTs; evaluation by a peer group in the frame of self-help groups; a few-months-long cohabitation with an already successfully operated patient "in order to form behavorial identification patterns and to learn tips for getting along in the desired role, as well as how to obtain food, clothing and shelter" (p. 392); contacts with the police; presence to inform oneself about name change and legal sex change; contacts to lawyers for name and legal sex change, transcribed diplomas, etc.; assignment of a "counselor, to provide advice regarding insurance, VA benefits, apartment rental, how to avoid being labeled by the surgeon as excessively narcissistic, manipulative or hsyterical" (p. 392); hormone treatment by an internist and a "general needs assessment via an experienced psychiatrist" (p. 392).
Patients were classified in category C when it was expected that they would never be adequate for sex reassignment. While patients of category B actually switched to category A, patients of category C took advantage of a treatment program in the sense of notable rehabilitation and subjective satisfaction without being operated.
Which treatment steps were taken is not to be learned in the publication. The surgical techniques (MFT) are described in detail with graphics and the images of the results are illustrated and it is also said "Cosmetic procedures are carried out one week later. These include augmentation mammaplasty (which may allow the patient to reduce the dose of estrogen postoperatively), rhinoplasty, thyroid cartilage reduction, or blepharoplasty" (p. 396); but any type of indication about and with what frequency every one of these surgical procedures or additionally mentioned counseling were made is missing.
The frequency of surgical complications in females that were primarily operated in Stanford was 47%. Those who were operated primarily somewhere else, 92%. The most frequent complications of the primarily operated elsewhere was that either there was no vagina made or that the vagina was too narrow (in eight of 12 females). Twice a rectovaginal fistula occurred; once the erectile tissue rests had to be recessed. In those who were primarily operated in Stanford, five rectovaginal fistulae, one urethrovaginal fistula and three vaginal stenoses were observed. Further complications were an irregular heartbeat and retarded wound healing. In two cases, blood transfusions were necessary, which were evaluated as complications. With the 24 males there were three surgical complications, namely, phalloplasty infection, rejection of the testes implanted and dehesion of the newly-constructed scrotum.

Results
Females: In the evaluation of the psycho-social area (economic, sexual, emotional and social) there is in sum an improvement for all females post-surgically in comparison to the pre-surgical situation. In the sub-group of the 34 females primarily operated in Stanford, the total score had only worsened for two females post-surgically. Thirty two had improved. Regarding the economic situation seven each were unchanged or worsened, but 20 had improved. The sexual situation was evaluated for 31 females as better and for three females as unchanged. The emotional situation was unchanged for 18 females, worsened for two and bettered for 14. The social situation was evaluated for eight females as unchanged, for three as worse and for 23 as being better.
Besides the already-mentioned surgical complications, two females sued for malpractice and one female each had a severe hysteria, resp., an excessive emotional attachment to the surgeon.
Sub-group comparison: The 34 gender dysphoric patients who were operated primarily in Stanford were divided into the sub-groups: transsexuals (N=18); homosexuals (n=13) and transvestites (n=3). These sub-groups' sum scores and the co-scores for the four dimensions of the evaluation were compared. In comparing the category "improved" with the category "worsened/unchanged" there were no significant differences among the three partial samples. Because of the small case number of the third group, ample statistical calculations were not done.
Males: Also for the males there was in the four psycho-social areas in the total sum scores post-surgically an improvement compared to the pre-surgical situation.

Follow-up Studies Mentioned
Benjamin, 1966

Authors' Conclusion
"In all scores, if the operation had an effect, it was one of improvement" (p. 399). "Our follow-up studies indicate that the transsexuals are not the only group that can benefit from this type of surgery. Indeed, for prognosis, it is probable that the diagnostic category is of much less importance than the patient's preoperative performance in a one- to 3-year therapeutic trial of living in the gender of his choice - with demonstrable economic, social, psychological and sexual success during that period" (pp. 401-402).

In addition to this evaluation by the authors, this remark is found at the beginning of the publication, "Surgery is not proven to be the treatment for the transsexual condition. Although psychiatry is reputed to be worthless, the presurgical requirements and the preparations are sufficiently structured to be, in effect, a form of behavioral modification therapy. Perhaps this may be of greater treatment value than the surgery. The next question to be answered is, 'Can surgery be withheld after success with our >behavorial modification< program?' " (p. 388)

Indication Recommendations
The indication recommendations result by the above-described criteria to integrate patients in category A, resp., the recommendations for patients in category B. The performance of surgical operations for sex reassignment based only on the desire of the patient is called malpractice.

Remarks
Besides the treatment team of the Johns Hopkins University Hospital in Baltimore, MD the Gender Identity Clinic in Stanford is among the most renowned institutions in the United States that treats transsexuals. There the diagnostic category of Gender Dysphoria Syndrome (Fisk, 1973) was formed with the help of which people with transsexual symptoms, oriented mostly to their previous history, are divided into different sub-groups. If the authors come to the conclusion here that surgical procedures can be of use for other groups of transsexuals, especially for homosexuals and transvestites, then this is an abbreviated expression form that leads to misunderstanding - meant were only patients who had lived at least one to three years absolutely in the other gender role, felt as members of the other gender, were treated with hormones, etc.; that is, they had the full picture of a progredient and an irreversible transsexual development without transsexualism having been fully present in childhood and adolescence. In biographical development, homosexual and transvestite behavior were predominant, but were finally overshadowed or substituted by transsexual behavior.
In the treatment program described in this publication (comp. Laub, 1973) it is noticeable how much weight is put on practical instructions for a role-conformed behavior; psychiatric counseling is only last - in 11th place.
Despite the many tables, the transmitted results give little overview and are very much in summary form only. There is absolutely no data about the process of the data gathering. The same is valid for the treatment patients received. The gathered data is very general in nature. The evaluation is arbitrary - for example, regarding prostitution behavior; the transformation of the measuring values in sum scores are not described and cannot be understood because of this.