Ball, 1981
Dept. of Psychiatry, University of Melbourne, Fitzroy, Victoria, Australia

This publication is interesting because it describes the beginning of the treatment of transsexuals in Australia. During his education in England during the post-War years, the author met, even before the popularization of the category transsexualism by Cauldwell (1949), an (Australian) patient who had the symptoms later described as being transsexual symptoms. Until 1964 he regarded surgical treatment methods for transsexualism extremely sceptically. Even for patients who were constantly in danger of losing their lives due to self-castration attempts, he considered that "surgery is probably best confined to some procedure which conceals rather than amputates the male organs" (Roth & Ball, 1964, citing p. 41). He shows how the historiess of transsexuals, as well as the treatment strategies by doctors, adapted to the conservative expectations of Australian society - for example, by negating homosexual contacts.

• Sample
• Type of Treatment
• Study Methods
• Evaluation Fields and Criteria
• Results
• Single Case Studies
• Suicide Attempts/Role Re-reversal
• Authors' Conclusion
• Indication Recommendations
• Remarks

Type of Treatment
Instead of representing the particulars of the treatment in the follow-up study sample, only the general proceedings of the Melbourne clinic is referred to. According to this, after an ambulant or stationary diagnosis, a two-year-long living in the female role was necessary before an indication to surgery was made. During this time hormone treatment was done. All surgeries were performed before 1976 and, except for the first two, all at one time.
About surgical complications it is said that five females had problems with the vagina. For an older patient, who had been operated as one of the first, half the vagina was lost. Two patients had bladder fistulae between surgeries that could successfully be tended to in one case, but in the other, stayed open despite many correction attempts. Another patient had a recto-vaginal fistula that could be treated without permanent damage. Finally, for one patient, the vagina was too small.
  

Study Methods
Personal contacts with the author, who had provided care for the patients before surgery. No systematic documentation.

Evaluation Fields and Criteria
The evaluation fields are partnership and sexual functioning ability. Criteria upon which these were evaluated were not mentioned.

Results
The profession, sexual activity and type of partnership relations of 23 females are represented in tabular form. All females were sexually active and four had not described difficulties during sexual intercourse. Five females had married and ten lived in permanent relationships that had existed between one and eight years. One patient had died - specifics are not given. The author emphasizes the "technical excellence of the surgical procedures ... and the good social adjustment in most cases, with the patients leading active, productive lives" (p. 42).

Single Case Studies
Two examples of prominent patients are described slightly more in detail, namely, a patient of a Maori family with eight sons, of whom, besides the described patient, another sibling had sex reassignment surgery in Cairo; one brother was homosexual and another a transvestite and possibly also transsexual. Besides this, a patient from a famous British family that reversed to the male role after the death of the mother to come into possession of the family's inheritance. This patient worked in her profession as a male and lived with a female. After the death of the partner she asked for new surgery because the previously-made vagina was obliterated. But she could distance herself from the wish for another surgery after some time.

Suicide Attempts/Role Re-reversal
Extortion attempts with suicide threats conduced to an exclusion from the treatment program. Quantitative references to this are not made. One female lived again as a male for a while, but without any desire to be re-reassigned (see single case studies).

Authors' Conclusion
The author emphasizes globally the excellent technical quality of the procedures and the good social adjustment of the females in most cases and attributed the good results to the selection criteria of the Melbourne team.

Indication Recommendations
The author has second thoughts that the surgeries are made accessible for mentally hardly stable patients, "and patients who may not be transsexual at all but have been led by themselves and others to believe they are so". The surgery for these "inappropriate" cases "can be disastrous and is irreversible. Prolonged psychiatric assessment remains essential" (p. 43). Fundamentally, the Melbourne treatment team requested one or multiple hospitalizations for diagnoses, a two-year success in the life in a female role and a hormone treatment before surgery. To work in the prostitution environment was not accepted as success in the female role. Contacts that existed previously to the homosexual sub-culture had to be given up by patients if they wanted to be treated.

Remarks
Remarkable is the indication of the author that during the 1940s and 1950s MFTs almost exclusively came for treatment and his simple explanation for it: the "lack of adequate technical procedures allowing penile construction for women" (p. 39). He worries that, with the popularization of the diagnosis and the treatment possibility, more and more patients come for whom this type of treatment does not promise any improvement. Because of this, he emphasizes the long-term pre- and post-surgical psychiatric treatment. Which goals are to be pursued by this treatment is mostly unclear.