Stein, Tiefer & Melman, 1990
Dept. of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

This follow-up study describes the results of about half of the patients operated at the above-mentioned institution in the course of three and a half years. The functional and cosmetic surgical results, the main focus of the presentation, seem to be extraordinarily good. The authors tried above all to record the subjective satisfaction or non-satisfaction of patients.

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

Study Methods
The primary author had an interview lasting 45 to 90 minutes with each of ten females, including a physical examination. For the other four females included in the follow-up studies, the evaluation came from their clinical files which contained records about contacts up to five months after surgery. The evaluation was done on a four-to-five step scale. The graduation for each item is not shared. A comparison or a statistical comparison of pre-surgical and post-surgical evaluations was not done.

Evaluation Fields and Criteria
To enable a comparison with other follow-up studies, interview questions were oriented on the questionnaire of Hunt & Hampson (1980a) and Hastings & Markland (1978), covering three evaluation fields: (1) economic, (2) social and (3) sexual situations. Also questions were asked about the post-surgical healing course, the use of dilators and the functioning of the vagina. "Whenever possible, questions with subjective answers were followed with related objective questions to minimize patient and interviewer bias" (p. 1188). Subjective evaluation of the females, for example, regarding the functional and cosmetic surgical results were compared to the evaluation of the researchers.

Results
The external and self-evaluations of functional and cosmetic surgical results correlate mostly and were -- in all except one case in which the evaluation was fair -- good, very good or excellent. "No patient believed that she was discovered by a lover to be a transsexual" (p. 1190). The above-mentioned surgical complications were treated successfully. The vagina depth was on average 15.3 cm. (9-18 cm., n=11) and the volume was as mean 48.6 ccm. (5-60 ccm., n=11). Eight of the ten interviewed patients experienced orgasms sometimes or frequently during sexual intercourse; nine produced sufficient lubrication so that they did not have to use a lubricant.
A special section is dedicated to the use of dilators. Even though all patients were asked to dilate regularly, five of the 12 did not keep to this recommendation, among them three of the four with a vaginal stenosis. The authors remark that two other females who also did not dilate had no problems with the width of the vagina. "This finding indicates that surgical technique and underlying patient physiology have an equally important role in this complication. Complications cannot simply be blamed on patient noncompliance and technical modifications must be considered after each occurrence" (p. 1191). Regarding the dimensions mentioned in the section Evaluation Fields and Criteria about economic, social and sexual situations, no summarized results are shared. Instead, rough data of the pre- and -- as far as applicable -- post-surgical evaluations for the following items are given in tabular form: parental support (no significant changes), friends (no significant changes), relations to sexual partners (significant improvements), gender of sexual partners (more male partners), drug consumption (unchanged), criminal activity (decreased), regretting the surgery, suicide attempts and thoughts, education, standard of living, consistence in work attitude and payer of the treatment.

Suicide Attempts
Pre-surgically seven of ten patients had suicidal thoughts and three of ten had attempted suicide at least once. Post-surgically two females had occasional suicidal thoughts; both had vaginal stenoses at first. After undergoing successful corrective surgery both females had no more suicidal thoughts. There were no post-surgical suicide attempts.

Follow-up Studies Mentioned
Abramowitz, 1986; Hastings & Markland, 1978; Hunt & Hampson, 1980b; Lindemalm et al., 1986; Lundström et al., 1984; Sörensen, 1981a

Authors' Conclusion
"The preponderance of current literature suggests that an operation is the best treatment option for certain carefully selected and psychiatrically prepared patients. Our findings support this conclusion" (p. 1191).

Indication Recommendations
The authors say, about the predicators for good results mentioned normally in the literature: "Unfortunately, the practical usefulness of this information is limited. We had no patient who repented the decision to undergo an operation or who committed suicide, despite the fact that our patients did not meet many of the positively predictive criteria. This finding is in agreement with the other reported surgical studies that used broad acceptance criteria similar to our." (p. 1191). All patients had to have lived pre-surgically at least for one year as females or either orchidectomized or treated with female hormones. They must have been at least 18 years old and a psychiatrist had to agree to the surgery without reservations.
Even though all patients of the study expressed regret that surgery did not happen much earlier, the authors do not think it makes sense to reduce the minimum age.

Remarks
The authors share mostly raw data. An inconsistency of the figures is found in table two,"psycho-social interviews" (p. 1190), with sample sizes up to n=12, even though only ten females had participated in the interviews. It is not clear if the primary author who conducted the interviews participated in the treatment of patients. Remarkable is the hint that vaginal stenosis, about which is frequently reported, are not necessarily the result of a lacking cooperation by the females in dilating, but just as frequently can be attributed to poor surgical techniques.