McCauley & Ehrhardt, 1984
Dept. of Psychiatry and Behavioral Sciences, University of Washington Medical School and Children's Orthopedic Hospital and Medical Center, Seattle, WA, USA; Dept. of Psychiatry, College of Physicians and Surgeons, Columbia University and New York State Psychiatric Institute, New York, NY, USA

The publication reports about the course research of 15 young FMTs who were diagnosed extensively and treated psychotherapeutically. One-third of the patients were operated in the course of treatment. The total group was researched.

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

Treatment Plan
The entrance examination included a semi-structured clinical interview, intelligence tests (Wechsler), Cornell-Index, Draw-a-Person-Test, Rotter Incomplete Sentences, Guillford-Zimmerman Temperament Survey and the Bem Androgyny Scale. Also included was a relative or a friend who had known the patient for years. The total examination included about four to six two-hour dates.
After this entrance examination the patient was taken on into psychotherapeutic treatment. At the earliest, they had come regularly one to two years at least once a month and were additionally 21 years old, then they were accepted into the program.
The treatment was done in three phases: (a) Initial phase with motivation and information; (b) Middle phase with special emphasis in the working of object relations and professional perspectives and (c) Final phase with focusing on the questions of sexual orientation. If all three phases were completed, it was called psychotherapy; if not, it was called counseling.

Study Methods
The follow-up study is based on the documentation of the yearly follow-up study dates, telephone contacts and correspondence.

Evaluation Fields and Criteria
It was evaluated how long the subject had lived as male or female and how the satisfaction was with their overall life situation and especially their gender role. Also it was asked about the wishes for other somatic reassignment measures and the overall functioning, psychopathology, sexual and social adjustment were evaluated.

Results
Of the five operated four lived and worked at the time of the follow-up study as males. Four lived alone, one with a (female) partner.

Suicide Attempts/Role Re-reversal
At the time of the entrance examination six of the 15 patients (40%) had attempted suicide at least once. Up until the follow-up study another patient who lived as a male but was not yet operated -- in connection with a partnership crisis -- attempted suicide.
One patient -- who had lived for two years as a male -- lived again as a female after hormone treatments and breast reduction.

Follow-up Studies Mentioned
Benjamin, 1966; Hoenig et al., 1971; Hunt & Hampson, 1980b; Lothstein, 1980, 1982; Meyer & Reter, 1979; Money & Brennan, 1968; Money & Ehrhardt, 1970; Pauly, 1968; Randell, 1969; Sörensen, 1981b; Stürup, 1976; Vogt, 1968; Wålinder & Thuwe, 1974

Authors' Conclusion
In view of the small case number and the average very young age of the patients as well as the socio-economic homogeneity of the sample, the authors don't think that their results are generalizable. They think that the following conclusions are the most important: (1) No patient reversed to the life of a heterosexual female. (2) Psychotherapy is of great use for these patients, especially the differentiation of homosexual and transsexual tendencies and improvement of familial and social relations. (3) The "persistence of a certain brittleness of gender identity" (p. 357). Even those patients who did not express any further interest in a sex reassignment report that at times of stress or depression the gender identity dysphoria was reactivated. Concluding, the authors emphasize that for the indication of somatic treatment measures the proceeding should be careful and slow. "Psychotherapy should be used as an intervention technique in all cases not as a deterrent to sex reassignment but as a means of helping patients to investigate openly the issues surrounding this complex choice" (p. 358).

Remarks
This publication is different from many other follow-up studies because a largely non-selected sample is represented, independent if a patient was operated or not. Under methodological viewpoints, one misses pre- and post-surgical comparison data in the follow-up study. Almost nothing is shared from the large amount of entrance data compiled. Four patients discontinued the contact either right after the entrance examination or moved to an unknown location, so that a course evaluation was, in reality, impossible. For the patient with a role re-reversal, one would have wished for a more explicit case presentation to understand this proceeding better.
Remarkable is the differentiation between counseling and psychotherapy that was not done formally - for example, by session frequency, but not by content. It could be doubted if the above-mentioned description of the contents and the frequency of 11 sessions over 43 months were sufficient to speak about psychotherapy having been done properly.