Stone, 1977
Dept. of Psychiatry, Los Angeles School of Medicine, University of California and Dept. of Psychiatry, Los Angeles and Harbor General Hospital, Torrance, CA, USA

This liaison/psychiatry publication is differential diagnostically oriented on Stoller's (1968) description of a conflict-free development of transsexualism on the basis of a female core gender identity. The author requests stronger selection criteria for the indication for gender reassignment surgery. Especially he demands that patients pre-surgically have to live at least five years in a stretch and unlimited in the female role.

• Sample
• Follow-Up Study Period
• Study Methods
• Evaluation Fields and Criteria
• Results
• Authors' Conclusion
• Indication Recommendations
• Remarks

Follow-Up Study Period
The patients were seen one or two days after the vaginoplasty during the stationary stay, as well as two to three years later because of a urological routine examination.

Study Methods
Psychiatric interview after the urological exam. Insofar as it was casually given, a partner was included.

Evaluation Fields and Criteria
Subjective experience of the surgery and loss of penis and testes, subjective experience of having a vagina, general coping with life, profession and relationship with the family.

Results
None of the females regretted the surgery, even though they had complications that made corrective surgery necessary (mostly deepening of the vagina). The females reported that they, in different measures, got along better in life. They remarked to be especially satisfied that there was a reconciliation with the original family.

Authors' Conclusion
Gender reassignment surgery is, in some cases, after careful psychiatric examination, the appropriate treatment form.

Indication Recommendations
As two of the most important indications the author suggests a five year living as female and a convincing appearance in this role with corresponding mannerisms. Persons who did not fulfil these two prerequisites and/or were married, had had children, practiced genital sexuality, had taken drugs during the previous year, suffered psychoses or other acute psychiatric illnesses or threatened suicide were excluded. Finally, those persons who did not refuse homosexuality for themselves or the partner were excluded.

Remarks
Usable quantitative figures are not contained in this publication. But it seemed important to us because of its indication thoughts. Oriented on Stoller's development theory, the author considers transsexualism as a nosologic entity. Diagnostically decisive is for him evidently the "prima-vista" impression in which he accepts his counterpart as female or not. The author demands, on one side, more strict selection criteria for which realization the psychiatrist in the interdisciplinary team is mostly responsible, and he declares "if the patient needs a psychiatrist, such need constitutes a contraindication to elective sex-change surgery and it is advisable to defer surgery until long after the need for psychiatric treatment is past" (p. 25). On the other side, "most" patients of his sample had had drug abuse and "some" had been in stationary psychiatric treatment. Reportedly they had many personality disorders and neuroses.
Something is arbitrary about this publication. The pre-surgical test phase of the other gender role demanded in the publication is established in five years. In the literature we have found no other place that demands such an expanded time period as a rule. It gives the psychiatrist who understood himself, as it was modern in those days of liaison psychiatry the diagnostically key role. At the same time patients who have conflicts are classified overall as unsuitable for treatment and those who could be suited for treatment as sane. ("Core femininity from non-traumatic and non-conflicting learning experiences with their mothers", p. 27), so that one has to ask if a psychiatrist makes sense for them. In reality, it seems,that it did not encumber the author if a patient got breast augmentation, cosmetic facial correction or castration, but only if it regarded vaginal surgery that he had indicated only for patients who impressed him "prima-vista" as being females.