Lothstein, 1982
Dept. of Psychiatry, University Hospital Cleveland, Cleveland, OH, USA

The author questions the global success rates for sex reassignment surgery of 68-86% reported until then, but not that single patients with gender identity dysphoria gain by surgical sex reassignment. For secondary transsexuals -- who are by judgment of the author the by-far bigger group -- in first line psychotherapy is indicated. He demands a more clearly differential indication and improvement of the methodological standards for follow-up studies.

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

Sample Overview
Chronologically the author cites clinical publications and follow-up studies and divides them, depending if they were published before or after 1970. For the selection of the cited publications, the sample size does not matter. Single case studies are regarded, especially if unsatisfactory results are shared in them. He found a total of 785 post-surgical patient reports (596 females and 189 males).

Of the follow-up studies from the 1960s he cites the authors Hertz et al. (1961), Benjamin (1966), Money & Brennan (1968), Money & Primrose (1968) and Randell (1969), also single case studies about unfavorable results. Of the follow-up studies from the 1970s he cites Money & Ehrhardt (1970), Hoenig et al., (1971), Arieff (1973), Gandy (1973), Ihlenfeld (1973), Laub & Fisk (1974), Hore et al. (1975), Wålinder & Thuwe (1975), McKee (1976), Stürup (1976), Meyer & Reter (1979), Hunt & Hampson (1980b), Lothstein (1980) and some single case studies.

Evaluation Fields and Criteria
He compiles the evaluation fields, resp, criteria that he found in the follow-up studies that he found in the 1960s and 1970s as "positive and negative result factors" (p. 426, appendix 2):

Results
"With one exception the follow-up studies up to and throughout the 1960s focused entirely on gross social-psychological measures of improvement. The consensus of these studies was that sex reassignment surgery was the treatment of choice for transsexualism. In spite of a few negative outcomes involving suicide (2), psychiatric disturbances (30) and role re-reversal (1), most investigators were optimistic about sex reassignment surgery. Citing an 80-90% cure rate for sex reassignment surgery, investigators generally accepted the fact that traditional psychiatric intervention was useless with transsexuals and that sex reassignment surgery was the treatment of choice for transsexualism. However, clinicians outside the area of transsexual research were not so accepting of these conclusions" (p. 419).

"The studies of the 1970s and early 1980s challenged the idea that sex reassignment surgery was a cure for transsexualism. While prior findings that sex reassignment surgery leads to better socioeconomic functioning for some patients were given additional support. Gender dysphoric patients were characterized as having severe psychopathology that was unaltered by sex reassignment surgery. As an outgrowth of these studies, it was suggested that candidates for sex reassignment surgery receive preoperative and postoperative counseling and/or psychotherapy. ... While some of the postsurgery studies attempted to identify predictive variables for use in patient selection for surgery, no uniform diagnostic criteria were identified or employed. Despite attempts to address the serious methodological problems of the earlier studies, the studies of the 1970s ended on a sour note. The media distortion of the Johns Hopkins results suggested that sex reassignment surgery was of little or no benefit - a conclusion unsubstantiated by the data but one that has become the focus of much debate" (p. 422).

Follow-up Studies Mentioned
Arieff, 1973, Benjamin, 1966, Gandy, 1973, Hertz et al., 1961, Hoenig et al., 1971, Hore et al., 1975, Hunt & Hampson, 1980b, Ihlenfeld, 1973, Laub & Fisk, 1974, Lothstein, 1980, Meyer & Reter, 1979, Money & Brennan, 1968, Money & Ehrhardt, 1970, Money & Primrose, 1968, Pauly, 1968, Randell, 1969, Stürup, 1976, Wålinder & Thuwe, 1975. (The writing was published 18 months after completion and so the overviews of Lundström (1981) and Pauly (1981) could not be regarded.)

Methodological and Ideological Issues
The author declares that the controversy pro and con sex reassignment surgery is based more on rhetoric than secure knowledge. The supporters see in the surgical procedure a palliative or even curative means for the treatment of the severe psychosocial illness of the patient. They consider it the best method and, as a rule, do not promise themselves anything from psychotherapy. They cited that the Commission of the American Medical Association on Human Sexuality (1972) has classified sex reassignment surgery for certainly diagnosed transsexuals as the treatment of choice and that in the book published by Brady & Brodie (1978) Controversy in Psychiatry, such treatments were mentioned in connection with medical standards for patients. The opponents see in it mutilating and anti-therapeutic procedures with which complex psychological, medical, legal, ethical and political problems are dodged. As a rule the opponents judge the prospects of success higher for psychotherapy.

To some methodological problems he subscribes to the opinion as follows. Sample: The patients compiled in follow-up studies are no casual selection of transsexuals, but only include such patients that have enough frustration tolerance to pass the extensive pre-surgical diagnosis and the Real-Life-Test. Many more patients find a place for surgery away from the Gender Identity Clinics on the free market. The author supposes that these patients who are not available for follow-up studies are more impulsive, more impatient and more demanding than those included in the Gender Identity Clinics. Also, as a rule, there are no control groups. Diagnostic criteria: There are no binding criteria for who is admitted for surgery and who is not. Treatment data: The treatment programs in different institutions are very different. The education and professional experience of the therapists differ widely. Documentation: Many times the basic data such as age, race and others are not shared, as overall the documentation about the starting situation of the patient (pre-surgical data) as well as the time intervals between the first examinations, treatment and follow-up are insufficient. Lacking operationalization of the success criteria: It does not suffice to constate and not define global subjective satisfaction of the patient or make evaluations that are graduated like school notes. Global psychological criteria are not enough. Depth psychological analysis is lacking. The success criterion "psychological functioning" is defined differently and can regard, for example, if patients consult a psychiatrist post-surgically or to test psychological comparison data or treatment results of long-term psychotherapy. Independence of the researchers: In many follow-up studies the prejudice of the follow-up researcher is notable.

Author's Conclusions
The author only excludes his own publication (Lothstein, 1980) from the general critique of follow-up studies. He questions the success rate reported about in literature of 68-86% without saying how the success rate corrected by his judgment could be expressed in numbers. He misses long-term follow-up studies. Generally, by his judgment, that is based on his own clinical experience and on the cited literature, it is evident that some patients with gender identity dysphoria can be helped surgically. Secondary transsexuals, to the contrary, can gain by all types of psychotherapy and he supposes that most patients with gender identity dysphoria are such secondary transsexuals. Patients wrongly diagnosed as transsexual need psychotherapy and not surgical treatment. "Indeed, sex reassignment surgery should only be considered as the last resort for a highly select group of diagnosed gender dysphoric patients" (p. 424). Differential diagnostic considerations as well as alternative treatment procedures and differential indication criteria should be worked out.

Remarks
Like Lundström (1981) and Pauly (1981) this publication is a reaction about the newly initiated controversies about surgical sex reassignment initiated by Meyer & Reter (1979) in the USA. The author reflects less the results themselves than the methodology of follow-up studies. He warns about unreflected positive and negative evaluation of the treatment procedure and its results. Rightly he demands a greater differentiation and a stronger methodology for follow-up studies. His judgment that most patients with gender identity dysphoria are secondary transsexuals or not transsexuals and that most may be helped with psychotherapy seems also very general and is not demonstrated by numbers in the publication (about the critique, comp. Lundström et al, 1984). The positive and negative result factors from the 1960s and 1970s are not very fruitful in the incomplete presentation presented by the author because they are too undetermined by content and because the author does not reflect that their formulation by the original authors already contains more evaluation than information - as it is also true for the selection done by him.