Kuiper & Cohen-Kettenis, 1988
Dept. of Medical Psychology, Free University of Amsterdam, Amsterdam and Psychiatric Clinic, University of Utrecht, Utrecht, The Netherlands

This research made by the suggestion of the Dutch Health Council (the highest council of the Dutch Ministry of Health) and by appointment of The Netherlands Gender Center Foundation (NGCF) was to answer two questions, namely (1) if the gender reassignment has the therapeutic effect that softens or removes gender identity dysphoria experienced by transsexuals and (2) how transsexuals evaluate the offered treatment. The follow-up study is very important because it is an almost total sampling of the transsexuals treated in The Netherlands and the researchers did not participate in diagnosis or treatment. The results were first published in the Dutch language (Kuiper, 1985).

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

Study Methods
Both authors and eight specially trained clinical psychologists conducted structured interviews with pre-determined answer alternatives. None of the interviewers was involved in the indication or treatment. All except three interviews were held in the living quarters of the interviewees. The satisfaction with one's own body was measured by the Body Image Scale (Lindgren & Pauly, 1975).

Evaluation Fields and Criteria
The authors considered subjective criteria in the evaluation of the treatment success as most important and asked, therefore, about the subjective well-being, integration and confidence in the new gender role, satisfaction with the new body, with the decision for surgery and satisfaction with the treatment, as well as suicide attempts. Additional to the subjective evaluation, other variables were collected (for example, employment, acceptance by the family, partnerships) and put in relation to subjective satisfaction. The high correlation of both expresses, in the judgement of the authors, the validity of the data.

Results
In the publication four groups are represented, FMTs as well as MFTs whose treatment was not yet finished and females,resp., males with completed treatment. We reflect in the following the results for the latter mentioned two groups.
Females: Nine females termed themselves very happy, 24 as happy, 14 somewhat happy, seven unhappy and one very unhappy. In their self-awareness 30 females never doubted to be a female and 24 females said that they had almost no doubts.
With their new gender role behavior 18 females were very happy, 28 happy, six undecided and two unhappy. The question on what type of effect the researchees had in their opinion on other females was answered by 42 females as very good or good, by eight as fair and two as very bad. Forty seven females had great confidence to be able to cope in the new gender role, six had fair confidence and one had no confidence.
The subjective satisfaction with certain physical characteristics (greatest satisfaction=1 to greatest non-satisfaction =5) was evaluated on average by the females as follows: vagina, 2.49; clitoris, 2.32; breasts, 2.43; voice, 2.74; facial hair, 3.31; body hair, 2.27. No female seriously doubted that the surgery was right for her.
Males: Post-surgically six males said they were very happy, 11 happy, seven somewhat happy and one unhappy. In their self-awareness 23 males had no doubts and two almost no doubts to be a male. With their gender role behavior four males were very happy, 16 happy and four undecided. Twenty three males believed to be integrated very well or well in the new gender role and two to be fairly integrated. High confidence to be able to cope in the new gender role were cited by 47 males and six had fair confidence and one no confidence.
The subjective satisfaction with certain physical characteristics (greatest satisfaction=1 to greatest non-satisfaction=5) was evaluated by the males on average as follows: penis, 3.25; testicles, 3.25; breasts, 2.66; voice, 1.75; facial hair, 2.75; body hair, 2.75. With one exception, the males had no doubts about the decision for surgery. This male did not doubt wanting to live in the new gender role.
For both genders it is to be highlighted as the most important result that the degree of happiness was independent of the treatment phase. In the view of the authors one can conclude that the treatment had no effect toward the subjective well-being. It is moreover to be supposed that the hope connected with treatment has a positive effect toward well-being independent of the fact if treatment is finished or not.

Suicide Attempts
Of the partial group (27 MFTs and 21 FMTs), about whom admission files with histories were available to the NGCF, 19% of the FMTs and 23.6% of the MFTs had attempted suicide. Two MFTs whose treatment had not been finished and four females with finished treatment had attempted suicide before and after treatment start. Of the NGCF patients of the last ten years, three MFTs committed suicide after beginning treatment. In which treatment stage they were or if treatment had been finished is not to be learned from the research. Among FMTs accepted for treatment, there was no suicide in the same time period.

Follow-up Studies Mentioned
Alanko and Achté, 1971; Benjamin, 1966; Blanchard et al., 1985; Hastings, 1974; Hastings & Markland, 1978; Hertz et al., 1961; Hoenig et al., 1970b; Hore et al., 1975; Hunt & Hampson, 1980b; Jayaram et al., 1978; Kröhn et al., 1981; Lindemalm et al., 1986; Lothstein, 1980; Lundström et al., 1984; McCauley & Ehrhardt, 1984; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1965, 1968, 1981; Randell, 1969; Sörensen, 1981a, b; Spengler, 1980; Stürup, 1976; Wålinder & Thuwe, 1975

Authors' Conclusion
The most important result is that the majority of the persons interviewed were happy or even very happy. Dysphoric feelings were, in as far as such were experienced, not due to gender identity problems.

Indication Recommendations
Because the gender reassignment is no "cure for everything" but can also lead to new problems, the authors recommend, besides medical, more intensive psycho-social care for patients.

Remarks
This publication is one of the few follow-up studies in which, even though futiley, it is attempted to verify data with comparison groups. Comparison groups should be persons who still want gender reassignment even though they have been denied it by the NGCF, that is, were not accepted into the treatment program. Only seven such persons could be found and all refused a collaboration. In the second comparison group people should be taken on who, during psychotherapy, had given up the wish for gender reassignment. Not one such person could be found.
The research is, as already mentioned, of great importance because of its large and almost complete sample. The Netherlands Gender Center Foundation is a central institution in The Netherlands that cannot be avoided by almost any patient desiring gender reassignment. It is an almost governmental examination suggested by the Health Council of the Ministry of Health of The Netherlands with a methodological overviewable and verifiable design.
Because the authors considered gender dysphoria as something that they could not measure with objective tools they concentrated research to subjective evaluations of the researchees. They consider it plausible that a healing, resp., decrease of the gender dysphoria also can bring an objectivizable improvement of the life situation, but they deem such secondary effects as inadequate to measure the success of the treatment. The theme "sexual behavior" was left out because they were of the opinion that "Transexuality, and therefore sex reassignment surgery, de facto, involves gender identity problems rather than sexual problems" (p. 442).
It is remarkable that the authors define sex reassignment surgery (SRS) as "the total process of adjustment to the other gender in social, legal, psychological, and physical terms" (p. 449). Defining SRS in these terms seems somewhat confusing as the American abbreviation SRS puts the emphasis unequivocally on surgical procedures even though they want to analyze the complete reassignment process.
Even though this is an ex post facto research -- which is true for all follow-up studies presented here apart, perhaps, from the one by Wålinder & Thuwe 1975, even though the authors don't point it out -- in which only data from one research time period is regarded and even though the subjective evaluation by the researchees is used as more or less the only measurement the results concur mostly with other follow-up studies. The patients experience that they gained by treatment of which the surgical procedure, resp., procedures, are only one aspect.