Pauly, 1981
Dept. of Psychiatry and Behavioral Sciences, School of Medicine, University of Nevada, Reno, NV, USA

The work, presented for the first time at the 6th Annual Meeting of the Royal Australian and New Zealand College of Psychiatrists in 1979 in Queenstown, was formulated as an answer to the follow-up study by Meyer & Reter (1979). The author defends his previous siding for the sex reassignment (Pauly, 1965, 1968, 1974a, b) against the questioning of the usefulness of surgical sex reassignment as well as reports about psychotherapies by which eight patients gave up the goal of a gender reassignment and it gives an overview about the previous decade, resp., the follow-up studies published after his earlier reviews.

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

Evaluation Fields and Criteria
The results are globally divided into categories "satisfactory," "unsatisfactory," "uncertain" and "unknown." The categories are not explained any further (as was the case in Pauly [1968]). The author claims, that in as far as the statements in the regarded literature were extensive enough, to have formed an evaluation that is independent from the original author and the judgment as a rule was more critical than that of the original author. A verification of this evaluation by the earlier extensively cited follow-up study by Randell (1969) does not confirm this claim by Pauly.

Results
Females: Overall the results for 202 females (71.4%) were satisfactory, for 23 (8.1%) unsatisfactory and for 48 (17%) uncertain. There were no statements about four females. Compared to the results reported earlier by Pauly (1968) and Benjamin (1967) the author's findings were:

Males: The results of the surgery were evaluated overall as satisfactory for 67 (80.7%) of the males. For five (6.0%) it was unsatisfactory and for 11 (6.3%) uncertain. Compared to the results reported by Pauly (1974a, b) and Benjamin (1966) earlier, the findings of the author were:

The conclusions that he draws by the secondary evaluation of publications by other authors and compares to previous publications: (1) "It is as correct to say today, as it was a decade ago, that a positive response to sex reassignment surgery is ten times more likely than an unsatisfactory outcome" (p. 49). (2) The results for females are on average better than ten years ago, the results for males on average worse. The reason for the different development is seen as being that for MF sex reassignment surgical advancements, as a rule, allow the creation of a functioning vagina and an aesthetically good vulva, which contribute to overall better results. Compared to this, phalloplasty still contains complications and the results are often unsatisfactory. (3) The results are overall better for males than for females. In Lundström (1978) it is explained that the females are diagnostically more heterogeneous. (4) The data presented here is, with high probability, nearer to reality than previous reviews, resp., follow-up studies that mainly came from one practice (Benjamin) or stemmed from many single case studies by authors who cited their own successes (Pauly, 1968, 1974). Most patients are being examined more exactly and have lived pre-surgically, to the contrary of before, at least one year in the desired gender role.

Follow-up Studies Mentioned
Arieff, 1973; Benjamin, 1966; Hastings, 1974; Hastings & Markland, 1978; Hoenig et al., 1971; Hore et al., 1975; Laub & Fisk, 1974; Lothstein, 1980; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1965, 1968, 1974; Randell, 1969; Sadoughi et al., 1978; Stürup, 1976; Wålinder, 1967; Wålinder & Thuwe, 1975; Wålinder et al., 1978

Methodological and Ideological Issues
The apologetic character of the publication is expressed openly and developed along the following arguments: (1) After Meyer & Reter (1979) and psychotherapists questioned if sex reassignment surgery is justifiable, it is necessary to present follow-up study results of a more recent time. (2) Since 1965, after the model of the Gender Identity Program at Johns Hopkins University in Baltimore, MD, USA, 40 comparable treatment centers have been created in North America. (3) The number of publications about transsexualism has increased greatly. (4) Since 1969 six International Gender Dysphoria Symposia have taken place. A professional association, the Harry Benjamin Gender Dysphoria Association, has been created and has been publishing treatment guidelines since 1979. In this way, a new discipline is created that conscribed to the research of normal development of gender identity and the research and treatment of gender dysphoric patients. (5) Gender identity dysphoria was accepted in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM III, 1980), and thereby formally recognized as a condition that has to be treated. The methodological problems of the evaluation of success, resp., dividing the results into certain categories are exemplified with the presentation of different examples of clitoris enlargement, resp., phalloplasty and the publications of Lothstein (1979) and Pierce et al. (1979). The general difficulties of the comparability of different follow-up studies are discussed.

Author's Conclusions
The general evaluation is identical to the previous judgment of Pauly: "A satisfactory outcome, as indicated by improved social and emotional adjustment is ten times more likely than an unsatisfactory result" (Pauly, 1981, p. 47; comp Pauly, 1968, p. 465). Diagnostically Pauly does not exclude, to the contrary of his attitude in his previous reviews, that patients who gave up wishes for sex reassignment with the aid of psychotherapy are, resp., were transsexuals. Instead of fighting an ideological war, he considers it better to try all possible treatment alternatives before referring for surgery.

Remarks
The challenge made by the follow-up study by Meyer & Reter (1979) and single case studies about patients who could work out their transsexual symptoms psychotherapeutically, the author answers with a relatively course statistic about success figures from follow-up studies from the previous ten years. The collection is by far not complete and compiles publications of very differing qualities. Methodological problems are cited but not discussed fully.