Mate-Kole, Freschi & Robin, 1990
Gender Identity Clinic, Charing Cross and Westminster Medical School, London and Ealing District Hospital, UK

This is the first and only prospective research in which two same sized groups of 20 MFTs each were divided by chance and were either operated within a short time or first treated psychiatrically for a long time. Two years after the first examination, both groups were compared regarding the psychological and social changes, wherein the group of the operated showed statistically significant more positive changes.

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

Type of Treatment
Patients were accepted into the treatment program and referred for surgery when they fulfilled the conditions mentioned in the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, that is, among others, there was a psychiatric diagnosis, at least a half-year long treatment to confirm the diagnosis and to exclude a psychosis. Additionally they had to demonstrate that they had lived and worked in the desired gender role for at least a year and could provide for their own livelihood.
Group 1 (operated): Patients were put on the waiting list to have surgery within three months and then operated as soon as possible. The surgery was done all at once (penectomy, orchidectomy and vaginoplasty). During the entire observation time there was psychiatric surveillance.
Group 2 (control group): Patients were treated with the routine procedure usual at the clinic. This means that a referral for surgery did not happen sooner than at the end of two years, during which patients were treated psychiatrically, and after that mostly had to wait another two to three years for surgery.

Follow-Up Study Period
The follow-up study was done for all patients two years after the first contact. For group 1 surgery was approximately 1.75 years previously. Group 2 was not operated at this time.

Study Methods
The research happened at three times: at the first contact, at the time of the decision for surgery and two years after the first contact. Each time it included a standardized psychiatric interview and a psychological test examination. In the psychiatric interview the following theme areas were recorded: family history, anamnesis, development, education, work history, partnerships and sexual relationships, beginning and development of the transsexual symptoms. As psychological testing procedures the BEM Sex Role Inventory (BSRI, BEM, 1974, 1977, 1981) and Crown Crisp Experimental Index (CCEI, Crown & Crisp, 1979) were used. Data obtained in the first contacts were compared with data obtained two years later. The significance calculation was done using McNemer-Test.

Evaluation Fields and Criteria
Compared were the following items about social behavior on a three-step scale (active, equal, less active): participation in group sports, participation in an individual sport, visits to family, friends etc., going dancing, going out to eat, visits to pubs etc., visits to sporting events, visits to the cinema and theater, club memberships, reading, television, playing, church attendance, sexual interests, professional activity and housework. (It is unclear if this is a self-evaluation or an external one.)
Also compared were the compiled neurotic fears (free-floating fear, phobias, manias, body-related fears, depression, hysteric behavior, compiled with the aid of several sub-scales of the CCEI and the masculinity, resp., femininity values according to the BSRI; see Mate-Kole et al., 1988).

Results
The group of operated showed, compared to the control group, at the two times compared, statistically significant changes in a series of social activities (participation in a group sport and an individual sport, contact to family and friends, going dancing, going out to eat, sexual interest). In the work life they stayed stable, where the control group worsened significantly. In five of the six sub-scales of the CCEI in the operated there was a highly significant decrease of neurotic fears, resp., a highly significant increase of neurotic fears in the control group.

Follow-up Studies Mentioned
Edgerton et al., 1982; Hamburger et al., 1953; Lundström et al., 1984; Meyer & Reter, 1979; Wålinder et al., 1978

Authors' Conclusion
Patients who were operated in the observation time period of two years showed, in comparison to the control group, a significant decrease of neurotic fears and became socially more active. With the unburdening made with the help of sex reassignment surgery for patients, demonstrated were a decrease of neuroticisms and an increase of social activities.

Indication Recommendations
The authors emphasized the importance of the indication criteria for surgical treatment written in the Standards of Care of the Harry Benjamin International Gender Dysphoria Association and mostly asserted that patients had to live one year long in the desired gender role pre-surgically and to provide for themselves.

Remarks
With this publication,for the first time a prospective study with a control group is presented that demonstrates that the surgical treatment can contribute to a measurable improvement of the situation of the patient. For the evaluation many variables are used that were not compiled in most other follow-up studies or were much more generalized. What is missing, as in most other follow-up studies, is a closer specification of the psychiatric care given. If one takes seriously the admittance criteria for indication mentioned by the authors, then one has to suppose that the first contact with the Gender Identity Clinic at the Charing Cross Hospital is not necessarily the same as the start of treatment. Because the group of operated were operated an average of 1.75 years prior to the follow-up study, between the first contact and the indication, an average of no more than three months could have passed. Since the time of a minimum of six months of psychiatric diagnosis and additional treatment is demanded for a diagnosis and the secure indication for surgery and also a minimum one year long in the successful life in the desired gender role, it has to be supposed that patients, as a rule, were in treatment elsewhere before their first contact to the Gender Identity Clinic. This is emphasized here particularly because one could gain the impression from the research that surgery indications were done within three months or less and then carried out. This naturally cannot be totally excluded because the authors thanked two colleagues (Peter Philip and James Dalrymple) for having provided them access to patients cared for by the two. We know patients from the Federal Republic of Germany who were treated there without documentation of any medical pre-treatment in their home country, indicated for surgery after a maximum half-hour long conversation and then operated the next day.