Green & Fleming, 1990
School of Medicine, University of California, Los Angeles, CA, USA

This review that appeared in the first volume of the Annual Review of Sex Research of English-language follow-up studies that were published between 1979 and 1989 and whose average follow-up study time was at least one year. Eleven follow-up studies are regarded and additionally the reviews by Pauly (1981), Lundström et al. (1981) and Abramowitz (1986) are cited.

• Sample Overview
• Evaluation Fields and Criteria
• Results
• Methodological Issues
• Authors' Conclusion
• Remarks

Sample Overview
The samples of the following publications were compiled: Blanchard et al. (1989); Edgerton et al. (1982); Fleming et al. (1982); Hunt & Hampson (1980b); Kuiper & Cohen-Kettenis (1988); Lindemalm et al. (1996, 1987); Meyer & Reter (1979); Ross & Need (1989) and Sörensen (1981a, b). Additionally it was inquired at the larger North American Gender Identity Clinics by phone if other publications were in publication or in print. This query brought about the indication to the publication of Mate-Kole et al. (1990) from the Charing Cross Hospital in London.

Evaluation Fields and Criteria
The results were divided into the categories "satisfactory," "unsatisfactory" and "uncertain," wherein the authors themselves characterized this classification as gross. "Generally, unless the patient is reported to regret the surgery, the outcome is considered "satisfactory." We recognize the inherent limitation of judging such results "satisfactory." We are also mindful of the propensity to report major life decisions as having been wisely taken. However, these gross categories are offered to provide a general impression of reported follow-up status, which must be elaborated upon further" (p. 164).

Methodological Issues
It is difficult to draw generalized conclusions because standardized selection criteria for surgery do not exist and standardized instruments for the measurement of the results and their evaluation are seldom used. Nothing important has changed about this in the 25 years in which the surgical treatment has been established at North American university clinics. The Standards of Care of the Harry Benjamin Gender Dysphoria Association are seldom mentioned in follow-up studies and, possibly because of this, also find little consideration in treatment. The samples are frequently small and this is why supraregionally made follow-up studies are necessary.

The question about representativity of patients compiled in follow-up studies is especially to be clarified because the number operated is many times greater than documented cases. Also it must be controlled in how far any changes of anxiety, depression, drug abuse, capability to keep up partnerships and similar are in causal connection with treatment or have developed over a course of time independent of treatment within the frame of a general personal development. It would be desirable to have detailed single case representation of post-surgical courses.

Author's Conclusions
The authors protest the policy of many private health insurance firms in the USA that deny to take over the costs for surgical treatment by claiming that they are cosmetic and/or experimental treatments. To call such procedures cosmetic is considered, in view of the suffering of patients, as cynical; to call the classification experimental is untrue, in view of the circumstances that such surgery is established in many centers inside and outside the USA and -- as is to be seen by follow-up studies -- has proven worthy. Other surgeries, such as liver and heart that are covered by insurance without question, are much more experimental. The authors finish pathetically saying "Helping these medical orphans was the goal of Harry Benjamin. It remains ours" (p. 174).

Remarks
The small literature selection of the review is to be criticized. The publications of Lindemalm et al. (1986, 1987) are, even though it is the same sample, evaluated twice. Remarkable is the evaluation of the author regarding the evaluation criteria of surgical, resp., treatment results. Despite their above-mentioned second thoughts about the widely dispersed result categories, they say, "Although, at first glance, basing outcome on the patient's statement that she or he does not regret reassignment may appear simplistic and naive, perhaps such a statement is sufficient" (p. 172), which simplifies too much. If the only thing that results from treatment is that a patient does not "regret" without that the treated feels better in any way, one has to ask what the big effort is all about. Finally, this evaluation disregards that follow-up studies are to work out differential indication criteria.