Ross & Need, 1989
Dept. of Psychiatry and Dept. of Obstetrics and Gynecology, Flinders University Medical School, Adelaide, South Australia, Australia

This follow-up study tries to answer if there is a connection between the quality of the surgical results and the post-surgical psychopathology. To be able to research this question a pre-surgical homogeneous and inconspicuous sample was analyzed. The quality of surgical results seems to be an important factor for the later coping of patients.

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

Study Methods
Physical examination: A pelvic examination that was done in seven cases by the previous surgeon and in another seven cases by a gynecologist who did not participate in the treatment, but was familiar with the treatment. The results of the research were entered into a standardized protocol and discussed by both examiners. In addition, seven females had urinary flow studies and additional measuring of residual urine.
Psycho-social evaluation: Done with the evaluation scale of Hunt & Hampson (1980a).
Statistical processing: Besides frequency counts, regression analysis (stepwise entry P<.05) was calculated and the operative and psycho-social variables were used as predicators for the Mental Health Status variable of the rating by Hunt & Hampson (1980a).

Evaluation Fields and Criteria
"Indices examined on a 5-point visual analogue scale (unless otherwise indicated) included the following: voice (gender consistent/inconsistent); breast size (too big/small); breast shape (realistic/ unrealistic); breast scarring (excessive/acceptable); genital hair growth (acceptable/unacceptable); genital scarring (excessive/acceptable); cosmetic appearance of external genitals (acceptable/ unacceptable); need for refashioning vulva (yes/no); urinary stream direction while sitting (vertical/horizontal); urinary stream caliber (spray/small stream); urethral meatus appearance (acceptable/unacceptable); urethral meatus erotic sensation (yes/no); urinary incontinence (yes/ no); problems with urethral stenosis (yes/no); erectile tissue around meatus (extensive/nil); problems created for patient by erectile tissue (yes/no); need for refashioning urethra (yes/no); location of erotic zones (open ended); achievement of orgasm (never/always); ejaculation on orgasm (yes, no, or don't know); satisfaction with sexual intercourse (satisfactory/ unsatisfactory); problems with sexual activity (open ended); and vaginal dimensions (length, diameter, direction). Vaginal dimensions were measured using a perspex dilator with gradations of measurement marked: a series of six glass and perspex dilators of varying diameters (varying by half centimeters) were used to assess width" (pp. 147-148).
The economic situation, interpersonal relations, psychopathology, sexual adjustment, additional surgery and familial contacts were additionally evaluated by the scale by Hunt & Hampson (1980a).

Results
Post-surgically half of the females had permanent employment and were financially independent; five females lived from public welfare support. Six females each had a long-term stable, resp., mostly stable relationship. Psychopathologic characteristics were found in five females; in two there were negative repercussions at work and with social relationships. Drug and alcohol abuse was observed twice, criminal convictions three times.
Partnerships were entered mostly with males. Two females each had no sexual relationships or called themselves bi-sexual. Sexual intercourse without problems was possible for 14 females, for one female each the vagina was too small for it or sexual intercourse was painful. Further correction wishes existed for nine females and they were considered as justified by the researchers in four cases. One female was not accepted by the relatives; all others were accepted to different extents. Regarding the decision for surgery one female afterwards had slight doubts sometimes if the decision had been right; all others found it as unquestionably right.
The variable of the surgical results show after dichotomizing at the scale median the following frequencies: cosmetically not acceptable results (0); genital scars (2); need for refashioning vulva (2); horizontal urine stream (2); dispersed urine flow (3); urine incontinence (4); urethra stenosis (3); erectile urethral meatus (6); dissatisfaction regarding this (3); need to refashíon urethral meatus (3); orgasm experience (12); ejaculation during orgasm (7); sexual dissatisfaction (0).

Follow-up Studies Mentioned
Ball, 1981; Benjamin, 1966; Blanchard et al., 1985; Hoenig et al., 1971; Hore et al., 1975; Hunt & Hampson, 1980b; Lundström, 1981; Pauly, 1965, 1968; Wålinder & Thuwe, 1975; Wålinder et al., 1978

Authors' Conclusion
"Where patients are selected on the criteria of absence of psychopathology and other factors with prognostic significance, surgical result is likely to account for a significant degree of the variance in postoperative mental state. The variables of Breast Scarring and Erectile Meatus together account for 82% of the variance; these are described by patients as the two variables most likely to alert partners to the fact (or to remind patients and partners) that the patient is not a "real" woman. These data suggest that the ability to pass as a woman (to oneself and possibly to others) is a critical determinant of postoperative mental state, and that the more telling the signs of gender reassignment, the more psychopathology accruing. Current social and family support are also apparently central to postoperative functioning, and it is reasonable to assume that this support also acts to reinforce the patient's self image as female... the adequacy of surgery plays a critical role in the postsurgical adjustment of the transsexual" (p. 152). A possible explanation for this is seen by the author in the self-image of the patient being an intervening variable that, influenced by the surgical results, modifies by itself the emotional well-being.

Indication Recommendations
Patients were selected by the prognostically favorable factors described by Wålinder & Thuwe (1975) and Wålinder et al. (1978) and also had to fulfil the criteria of emotional stability (Ball, 1981). Pre-surgically they had to live at least two years as a female.

Remarks
This publication intends to research what all other follow-up studies either neglect or answer contradictorily, namely, what influence the quality of the surgical results has on the further well-being of the patient. Probably the contradictory results of the other follow-up studies are to be attributed that there was too little control about how patients should be judged pre-surgically under psychopathologic aspects.