Meyer & Reter, 1979
Dept. of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA

This follow-up study, started in the year 1971 -- whose results were presented for the first time at the Annual Meeting of the American Psychiatric Association, May, 1977, in Toronto, Canada and was then hardly noticed -- has found in the Western professional world and also in the lay press, a great resonance after its being published in the Archives of General Psychiatry in August 1979. One can call it the most noted and disputed follow-up study, where the dispute was less by its many times falsely-cited results than the accompanying statements of the first author who saw a connection between this publication and the stopping of sex reassignment surgery at the renowned Johns Hopkins University Clinic.
In this clinic a sex reassignment surgery was done for the first time in a North American university clinic in 1960. More specifically, a double-sided sub-cutaneous mastectomy was performed on an FMT. Previously it had only been available abroad and maybe in private clinics for US-American patients - so it was, through this act, converted into a serious treatment, even though it was not undisputed. Like the first surgical procedure, the establishment of the Gender Identity Committee at the Johns Hopkins University Clinic some years later (1965) was a signal for other US (American) university clinics.
Correspondingly noticed were press releases that sex reassignment surgery was not done any more at the Johns Hopkins University Clinic; it was connected to the publication of the follow-up study by Meyer & Reter. (TIME took the study to demonstrate that there are "no differences in long-term adjustment between transsexuals who go under the scalpel and those who do not". The New York Times cited Meyer, "My personal feeling is that surgery is not a proper treatment for a psychiatric disorder and it's clear to me that these patients have severe psychological problems that don't go away following surgery" [both cited from Fleming et al., 1980, p. 451, but there without giving dates or pages]). In reality, the stopping of surgery had other reasons than the results of the follow-up study: namely, first, the resignation of the surgeon, second, that the Johns Hopkins University Clinic wanted to make pioneer work and did not follow up with once-established treatment methods to keep more research capacity free and, finally, the personal rivalry within the Gender Identity Committee had an important role (comp. Lothstein, 1980; personal writing from John Money to F.P.). Disregarding these circumstances, patients with transsexual symptoms were still diagnosed and given psychiatric care, and in as far as indicated, were transferred somewhere else for surgery.
The idea of the follow-up study was to stop for a moment after the gender reassignment surgery became, in a certain way, routine, and see the long-term results ("To step back from 'normalization," p. 1010).
The description of the research group forces the conclusion that the samples described by Money & Ehrhardt (1970), Money (1971) and Jones (1972) are contained in the sample of Meyer & Reter without being so noted.

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

Study Methods
The primary author -- who participated in the indication and treatment (at least with the non-operated, resp., those who were operated in a course of the follow-up study) -- made two to four-hour interviews. They were done on tape, transcribed and evaluated later on. The non-operated were considered as an approximation for a control group for the operated. Because in the course of the follow-up study, 40% of the originally non- operated were operated, the authors finally made three principle groups (operated [n=15], operated in the course of the follow-up study [n=14] and not operated [n=24]) and further sub-groups (operated at the Johns Hopkins Clinic or somewhere else; operated with or without complete pre-treatment).

Evaluation Fields and Criteria
Contents of the interviews were questions about the present adjustment (for example, residence stability, education, profession), biographical adjustment(for example, family bonding, educational curriculum) and finally about fantasies, dreams and sexual activities.
Only that information that the author classified as observable and objective from the first interview part were regarded in the publication. They were divided into four categories based on the following scoring system:

Results
Professionally, the operated and not operated improved marginally, where the improvement for operated was slightly greater. For the operated the psychiatric contacts decreased from 33% to 8% and in the comparison group from 72% to 28%, wherein those contacts were mostly about forcing the admission to the operation. The number of psychiatric hospitalization no mentionable differences were established. Also regarding the residence stability the research and comparison group did not differ notably.
More important than these single aspects are the results of the global evaluation obtained by the scoring system described above. For this the three main groups (operated, operated in the course of the follow-up study and not operated) were compared. For all three groups it was found that the mean values improved and the range and standard deviation were smaller. Also the mean values among the three groups did not differ statistically significantly at the time of the follow-up study. On average, the sub-group with the worst scoring were those who had abandoned the treatment program at the Johns Hopkins University and obtained the surgery somewhere else. Among the original operated, those seemed to score on average somewhat better were those who had lived the trial period, that is, the pre-surgical life in the other gender role most consequently. Single scores for the sub-groups are not shared because the procedure by which the results were obtained was methodologically questionable (see remarks).

Suicide Attempts/Role Re-reversal
One male had, in connection with phalloplasty, severe complications and wanted -- after multiple unsuccessful corrective surgeries -- to have the newly made penis removed again without questioning the other steps of the sex reassignment. This patient was, for a short time, in psychiatric inpatient treatment for drug dependency and suicidal tendencies.

Follow-up Studies Mentioned
Benjamin, 1966; Edgerton & Meyer, 1973; Hamburger et al., 1953; Hastings, 1974; Hore et al., 1975; Money, 1971; Randell, 1969

Authors' Conclusion

Indication Recommendations
"At the most simple level, these data suggest that significant change in adjustment scores may be achieved either through surgery or through the passage of time in association with some contact and acceptance into an organized evaluation program. Operated patients who could not withstand the rigors of a trial period of living and working in the desired gender role clearly did less well than the unoperated subjects or their fellow operated subjects...None of the operated voiced regrets at reassignment, the operative loss of reproductive organs, or substitution of opposite sex facsimiles (except one, previously noted). Socioeconomically, operated and unoperated patients changed little, if at all " (p. 1014).
The authors summarize "the most conservative interpretation of the data is that among the applicants for sex reassignment there are operationally two groups who, in the face of a trial period, will self-select for or against surgery, and that in either instance improvement will be demonstrated over time, as judged by observable behavioral variables. Sex reassignment surgery confers no objective advantage in terms of social rehabilitation, although it remains subjectively satisfying to those who have rigorously persued a trial period and who have undergone it (p. 1015).

Remarks
Because this publication is cited frequently by the professional and lay literature it seems important to us to demonstrate extensively why the results of this work are not very enlightening and cannot support the conclusions derived from them.
The scoring system used by the authors is undifferentiated because it is, for example, not evident if an arrest happened because of cross-dressing or for real crimes; if the partnerships classified as gender-appropriate, resp., as nongender-appropriate were partnerships of operated that existed over the time period of the operation or they were entered into post-surgically; if they are living partnerships or sexual partnerships; if the surgical results permitted to have sexual intercourse or not and if the psychiatric contacts, resp., inpatient treatments, came about exclusively because of the persistent pursuit of the goal sex reassignment or happened because of other psychiatric illnesses. One does not learn, for example, if also the routine contacts to the care-providing psychiatrist are counted or not.
The valuing done by the authors is absurd because, for example, the gender of the partner with whom a patient lived was evaluated pre-, resp., post-surgically as opposite. A single who possibly was not capable of having a long-term relationship and not maintain it received a better score (0) than an MFT who had lived for years with a female friend (and had an intimate relationship?) and did this past the time period of the operation, but whose relation after the operation was evaluated as nongender-appropriate (-1). An inpatient psychiatric treatment was evaluated more negatively (-3) than a jail term (-2). The professional of plumber (Hollingshead job level 4) counted exactly as much as post-surgical "gender-appropriate marriage" (+2).
The tables and figures shared by the authors do not seem serious because after the scoring table a maximum of only eight minus and five plus points can be achieved, but in the results table (p. 1014) a range from -18 to +19 points is given. How these figures came about remains totally in the dark. The presumption made by Fleming et al. (1980) that every category could be scored multiple times, is negated by the following thought: It is imaginable that with a multiple evaluation a number of 18 minus points can come about - by three stationary psychiatric admittances (3 times -3) plus three jail terms (3 times -2) plus three "nongender-appropriate partnerships" (3 times -1). It is unfathomable, however, how 19 plus points can be achieved with the scoring system,unless by, for example, five gender appropriate marriages (5 times +2) plus three different academic professions (3 times +3) within a follow-up study period.
One asks the question how it came about that a renowned professional publication published such opaque figure material. Meyer & Reter considered the shared data for the, in a sense, most objective data of their sampling and left out as good as all subjective statements of the follow-up study. It is possible that there was more to be learned from them.
Not without a problem is also the use of the not-operated as a control group, especially because 40% (14 of 35) of the not-operated had surgery in the course of the follow-up study and the other 21, even if not very decided, further pursued the goal to be operated. If the operated, in the course of the follow-up study, were counted in the partial sample right away of the operated, the average follow-up study period would have been shortened. How the other results could have been changed by this cannot be fathomed; the authors do not have any comments or calculations for this (comp. the remarks to the publication by Edgertom & Meyer [1973] and the critiques by Fleming et al. [1980], Lothstein [1982] and Abramowitz [1986]).