Lothstein, 1980
Dept. of Psychiatry, Case Western Reserve University, Cleveland, OH, USA

A Gender Identity Clinic was established at the Case Western Reserve University in Ohio between 1974 and 1975. The seven females (group I) previously operated there were compared with a second group of 14 operated patients who were treated in the Gender Identity Clinic under the aspect how the psychiatric, resp., psychotherapeutic treatment had worked.

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

Study Methods
Both groups were researched by different methods. For group I clinic files used as a source contained data of a maximum of one year post-surgically. Besides this, discussions were held with the previously treating physicians. For group II a questionnaire was developed, containing 59 items, to be filled out by patients during routine visits after three months, after six months, after one year and further on each year - which, however, did not happen regularly. One patient refused to fill out the questionnaire. Additionally, non-systematic information from each of the patient's psychotherapists, other patients and occasional home visits were included. Group II was analyzed and tested psychologically with the MMPI. The author participated in the treatment (at least of group II).

Evaluation Fields and Criteria
The questionnaire contained open-ended and Likert-scaled items about the sexual, psychological, environmental, economic, parental, familial, medical and social adjustment and functioning.

Results
The females of group I had many minor surgical complications (vaginal stenoses, infections, dysuria). Four females had vaginas too shallow for sexual intercourse, but did not have corrective surgery for it. None of the females of group I regretted the surgery. In group II all females with one exception (rectal-vaginal fistula and vaginal stenosis) were satisfied with the surgical results.
The social-psychological adjustment of group I is classified from poor to fair. One of the patients of this group became psychotic for a few hours immediately following surgery. In group II five immediately post-surgical psychotic episodes disappeared spontaneously. The MMPI (testing) showed no statistically significant personality changes between measuring times pre- and post-surgically. Measured by polarity profiles patients showed to be less fixated on a gender stereotype in comparison to the pre-surgical situation.
In group I 75% of the females were unemployed; in group II all persons lived and worked in the new gender role. The work situation had improved in this group for 64% and had worsened for 7%.
The sexual life had improved for 67% of the males and females of group II. Post-surgically no significant increase of sexual activity or number of sexual partners was noted. Females tended to get new partners, while the males stayed with their respective previous partners.
Criminal convictions and alcohol abuse were not observed in group II post-surgically.

Suicide Attempts/Role Re-reversal
Pre-surgical suicidal tendencies are not documented. Post-surgically a female from group II was hospitalized short-term because of a severe depression and suicidal tendencies; two females and three males expressed suicidal thoughts in the first post-surgical year, but not later on.

Follow-up Studies Mentioned
Benjamin, 1966; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1968; Randell, 1969; Wålinder & Thuwe, 1975

Authors' Conclusion
The author evaluated his results as a relative affirmation of previous follow-up studies, insofar as 65% of his patients had improvements in the social and psychological areas. On the other hand, this percentage is clearly lower than the figures of previous follow-up studies, where it was reported that about 84% of patients had improved. The author's intent is to negate the dictum that psychotherapy is useless for transsexuals. For this he compares both groups, of which the first did not have psychotherapeutic counseling; the second group had psychotherapeutic counseling pre-surgically and post-surgically. It is especially noted that patients are in a process of constant changing post-surgically, so that the proceedings of other follow-up researchers are insufficient because they only regard a momentary situation of the patient at a certain point of time. Course observations are superior to that. At the earliest, one can make a relatively secure judgement about treatment results two years after the surgical procedure. Psychotherapy can help stabilize patients in some cases without pursuing a surgical solution. Besides this, psychotherapy is mainly important post-surgically because a therapeutic alliance often is only established only after surgery. The opinion that a sex reassignment surgery makes psychotherapy dispensable must be revised. The problems of the patient are fixated psychologically after surgery and are, therefore, not to be solved by a surgical procedure alone; they require a continuing psychotherapeutic treatment.

Indication Recommendations
The conditions for admittance to group II were: minimum age of 21 years; a marital status of single or divorced; successful professional life in the new gender role for at least one year; a somewhat clear emotional stability; physical health; no severe conflicts with the law.

Remarks
The intention of the author to demonstrate the necessity of pre- and post-surgical psychotherapeutic additional treatment can be supported by clinical experience, even though his data is hardly adequate to demonstrate this necessity. Data about the beginning and duration of hormone treatment and details about the surgical treatment are missing. Most of all, it cannot be discerned by his representation how many and what types of psychotherapeutic contacts patients had and what was attempted within psychotherapy. Even though the author said that polysurgical wishes were not observed, he reports about problems regarding the depth and width of vaginas and medical results in the vulva, as well as wishes for smaller hands and smaller Adam's apples, for wider hips, less beard and higher voices. For males, the unhappiness regarded the unsatisfactory result of the phalloplasty. Patients who had this procedure made were especially susceptible to conflicts and depressive reactions post-surgically.
Statements of the objective surgical results and the subjective reactions to them are contradictory. In view of the small sample, the percentages used are not adequate. The data about group I, that served as a control group, is so meager that comparing calculations cannot be done.