Pauly, 1965
Dept. of Psychiatry, University of Oregon Medical School, Portland, Oregon, USA

In this overview the historical, psychopathologic, aetiological and epidemiological aspects of transsexuals are discussed. This publication compiles 100 cases about MFTs in professional literature found by the author. These sources were 54 publications from 13 countries (Germany 24%; USA 20%; France 17%; Switzerland 11% and others 28%) and in seven languages (German 33%; English 33%, French 22% and others 12%) in which single case studies of smaller or larger samples of transvestites/transsexuals were described. The author extracted from these publications those cases that, by his evaluation, were MFTs. As far as possible, he extracted data about age, profession, marital status, sexual behavior, familial background, physical findings, psychopathology, psychotherapy, hormone treatments, surgical procedures and follow-up studies.
Finally, he compared the data of the sample compiled in professional literature with another sample under two points of view, namely the portion of operated on one side and the gender on the other side. We will first refer to the overview and after that, to the data of Pauly's "own" sample.

• Sample 
• Results 
• Follow-up Studies Mentioned
• Methodological and Ideological Issues
• Authors' Conclusion
• Remarks

*Cases compiled from the professional literature. Of the single follow-up studies presented in chap. 3, only the publication by Hertz et al. (1961) was regarded.
**The mean age at the time of the first surgery was 32.2 years (range 19-42 years; comp. Pauly, 1968, where the same mean value is found for a sample compiled differently, but with a range from 19-58 years). The follow-up time measured from the first surgery ranged from 6 months to 25 years (comp. Pauly, 1968, where the same sample, resp., the enlargement with Benjamin's samples, arranged for the follow-up time is given from 3 months - 13 years). It is remarkable that 19% of the patients were diagnosed as manifestly psychotic and 20% (pre-surgically?) were psychiatrically hospitalized. Suicidal threats (35%), suicide attempts (17%), as well as self-mutilation attempts (9%), penis amputations made by the patients themselves (3%), resp., self-castration (6%) had forced more or less a significant amount of the surgeries for sex reassignment, resp., its continuation.

Results
The author repeats the evaluation of the primary authors. According to this, of 48 of the operated, 20 evidently improved and six did not evidently improve - among them a patient with the desire for role re-reversal. Eleven were unchanged or wanted further surgery. There is no post-surgical data about the 11 remaining patients. Twelve could achieve a legal sex change following surgery.

Methodological and Ideological Issues
The author's attempt mainly was to extract most "objective" data of the described group of patients in the compiled literature. He does not treat methodological problems of the follow-up study in the narrow sense.
Regarding the aetiology his evaluation and the texts evaluated by him speak for a psycho-social rather than for a biological explanation. Regarding psychopathological aspects he considers a division of transsexualism from homosexuality and psychoses as necessary and possible.
Regarding the discussed about question if in treatment the psychotherapeutic or the somatic procedure is to be preferred; his evaluation leans towards the latter. As arguments for somatic treatment procedures he names: (1) Psychological determinants are for gender role behavior more important than physiological ones. (2) Emotional disturbances and psychiatric illnesses are also treated somatically. Lobotomy and electroconvulsive treatments have been used empirically for relief of symptoms in this regard. (3) It would be inhuman not to help these desperately unhappy individuals or to force them into long-term psychotherapies, especially because their hope for success is small. To the contrary of this, surgical procedures are faster, more economical and, most of all, successful. As arguments against somatic treatment procedures, he names: (1) Such procedures are unethical and immoral. (2) One can seriously doubt the success of the treatment. The simple statements of patients that they are happy to be operated is not a sufficient success criterion. And then there is the question by which the success is to be measured, for example, by depressive episodes, partnership behavior, links to prostitution, wishes for perfecting (surgical results) or similar. (3) Psychotherapy may not be able to heal the patient, but it could help them to concile with their situation. The author noticed that, concluding from the reports reviewed by him, it was easier for patients to find a surgeon if they had previously made auto-mutilations (see below). He sees a connection between the harsh criticism of physicians who perform such surgery at all and such backgrounds and declares that it is inappropriate to declare physicians who opt for surgical procedures as overall incompetent.

Author's Conclusions
Pauly recommends reservation in the evaluation of the data compiled by him because success criteria are not to be easily determined and the author who reports about his own cases has a wide interpretation possibility. He also believes that, in the literature seen by him, more positive than negative results were shared because of the discussion about sex reassignment surgery. To the 100 cases compiled by him from professional publications, he adds, finally, the above-mentioned very heterogeneous sample (see sample overview) and calculates from this the total number of cases described in the literature to 603 FMTs (94 females) and 162 FMTs (19 males) and he concludes: "Follow-up studies at the present time indicate some apparent success, but these results must be interpreted with caution" (p. 179).

Remarks
This overview, as well as the later ones of Pauly (1968, 1974a, b, 1981) is among the most frequently cited publications about transsexualism and contributed -- besides the publication of Benjamin (1964a, b, c, 1966) and the compendium published by Green & Money (1969) -- that transsexualism was given attention in the academia. This publication witnesses how different the therapeutic procedure was at that time point. Only about two-fifths of those operated had a vagina made. Evidently in many cases pre-surgically and in some post-surgically there was no hormone treatment. About the psychiatric and/or psychotherapeutic treatment, there are no useable statements.

The purpose of the publication is to construct a picture of transsexualism from the mosaic pieces of dispersed single case studies, to make a provisional evaluation of the published surgical reports and to highlight the necessity of systematic research of which the author expects a better understanding of gender roles and psychosexual development. Besides this, the attempt to legitimize surgical treatment procedures is undeniable.

The diagnostic classification, as well as the evaluation of treatment courses of single patient histories, cited by Pauly are questioned extensively by Springer (1981).