McEwan, Ceber & Dawns, 1986
Queen Victoria Medical Centre, Melbourne, Australia

This is a follow-up study under almost exclusively surgical viewpoints with explicit presentation of surgical techniques (not repeated here) and remarks about surgical risks and complications.

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

Type of Treatment
All patients had a vagina made, whereby mostly as surgical technique a peritoneal and abdominal access was selected. Beside the surgical proceeding other therapeutic interventions are not mentioned. The following surgical complications were registered regarding the 68 treated females: rectal perforation (n=4); anus preater (n=2); recto-vaginal fistula (n=1); haemorrhage that had to be stopped surgically (n=6); neovaginal prolaps (n=2); necrosis of the vaginal skin tube (n=4). For nine of the 23 females a total of 17 corrective surgeries were done: extension of the vagina (n=4); changing of the urethra exit (n=3); reduction of the urethra exit (n=4); reduction of the labia (n=1); revision of the posterior vaginal fold (n=5).

Study Methods
The authors participated in the treatment. The females were examined physically and answered a questionnaire.

Evaluation Fields and Criteria
The females evaluated the following criteria on a four-step scale (poor, resp., worse; fair, resp., unchanged; satisfactory, resp., somewhat better; from good to excellent): appearance of the genitals, depth of the vagina, genital experience, capacity for orgasms, self-image, work situation, social situation, sexual life and overall evaluation. Also the frequency of surgical complications and the depth and width of the vagina were evaluated by the authors, wherein a depth of 10 cm. or more and a width of 35 mm., or two fingers, was evaluated as being adequate results.

Results
In a total group (n=68) 65% and in the follow-up study group (n=23) 78% of the females had an adequate vagina for sexual intercourse by the criteria of the authors. But eight of the nine females whose vaginas were estimated by the authors as not sufficient nevertheless had vaginal intercourse. The depth of the vagina was evaluated by six females as good to excellent, by ten as satisfactory and three each as fair or bad. The appearance of the genitals were evaluated by 29 of the 23 females as good to excellent and by three as satisfactory.
The genital feelings were estimated by 18 of the 23 females as good to excellent, three as satisfactory and one as fair, resp., unchanged. Sixteen of the 18 females who had sexual intercourse achieved orgasms by it and three of five who had no intercourse experienced orgasm during masturbation. Subjectively 14 females evaluated their capacity for orgasm as good to excellent, seven as satisfactory and one as poor.
Their self images were evaluated by 21 females as good to excellent and only one as fair. The working situation was described by 19 females as good to excellent and by three as satisfactory. The social situation was described by 18 females as good to excellent, by two each as satisfactory, resp., fair and one as poor. Overall 18 of the 23 females evaluated the results as good to excellent and three as satisfactory.

Suicide Attempts
One female committed suicide after a technically successful surgery. The authors attributed this suicide to working place loss and partnership problems, especially because the patient had expressed happiness about the fact she had been operated.

Follow-up Studies Mentioned
Benjamin, 1964a; Hamburger et al., 1953; Laub & Fisk, 1974; Pauly, 1965

Authors' Conclusion
In the authors' opinion a patient who wants to undergo gender reassignment surgery must know that the results will not be perfect or ideal. The complication rate is high (35%), although in most cases correction is possible later.

Remarks
This publication mostly describes surgical complications and is informative in this field. It is problematic that, finally, the percentage of complications cannot be exactly calculated because they worked with different partial samples, wherein it remains open how the complication rate is represented in the other partial samples. The psycho-social part of the follow-up study is weak because it is much too vaguely dimensioned.