• Selection of publications
• Processing
• Presentation of results

Selection of publications
Included were all single publications we could acquire and which were considered as follow-up studies and which reported the post-surgical results or transcourses of at least five females and/or males. We interpreted the term -- of what is to be follow-up -- rather broadly. Therefore we also included publications that had rather the character of information than of scientific follow-up studies to show the amplitude of the spectrum of examination intents and the institutions participating in the examinations. We did this especially if such "follow-ups" were mentioned or cited repeatedly in other follow-up studies.

When an author or group of authors mentioned repeatedly the same research sample, we have noted same. Excluded were individual case reports and samples in which less than five patients were involved, because -- as a rule -- you cannot draw general conclusions from them. We did not consider -- except for one in the renowned professional publication Archives of Sexual Behavior which we used for illustrative purposes (Sadoughi, et al., 1978) -- works that contain exclusively psychological test comparative data without documenting the course of treatment and other treatment results (review in Lothstein, 1984; comp. also to Abramowitz, 1986). Also not noted were all general works about transsexualism in which post-surgical results are mentioned only in passing. Even though we tried to make a complete body of research, the supposition that we overlooked some works is probably correct. Despite our multiple requests, a number of speech manuscripts presented at various International Gender Dysphoria Symposia during the 1970s in the U.S.A. and at conferences of the Harry Benjamin International Gender Dysphoria, Inc., were not made available to us. Insofar as other authors cite these works, we have included them in our bibliography. We don't consider this lack of documentation critical, because substantial conference contributions, as a rule, are published. Subsequently, this lacking documentation should be considered as preliminary research only.

Because of the above-mentioned selection criteria, a series of clinically and theoretically relevant works with large patient samples could not be considered because they emphasized typological aspects (e.g., Bentler, [1976]; Fleming et al., [1981, quoted by Beatrice]; Beatrice, [1985]; Blanchard, [1989 a, b]) or do not report post-surgical development and results. This is especially valid for older works written in times in which sex changes were normally not available. For example, the works of Binder (1933); Bürger-Prinz & Weigel (1940); Bürger-Prinz et al. (1953, 1966); Randell (1959); Burchard (1961, 1965) and Wålinder (1967) should be mentioned. The last cited work was expressly not intended as a follow-up study, but belongs to the best clinical documentations and contains short descriptions of post-surgical transcourses, so that we thought that we had to mention it at least in passing.

In comparison to the large number of individual works, we mention relatively few overviews or reviews and only those which were conceptualized as reviews. There is a large volume of work of varying quality about transsexualism that, in passing, contains a section of follow-up results. As a rule, these sections are superficial and based only upon a very small excerpt of published follow-ups (e.g., Walters et al., 1986). There are also works that announced in their title a review, but miss the theme by far (e.g., Thimm & Kreuzer, 1984). We did not consider such works. On the other hand, the number of individual examination reports contain good literary overviews. The works of Wälinder (1967); Wälinder & Thuwe (1975); Lundström (1981) and Kuiper (1985) are to be emphasized. We did not mention them again in the section of reviews in order to avoid redundancy.

Processing
Every follow-up study was, by each of the authors separately, summarized in accordance to common criteria. These excerpts were then compared and varying values checked; different conclusions were discussed and adjusted. In the criteria the following items were included: name of the author(s); year of publication; institution and country; description of the samples (N by gender and age group), the control group and the comparison group; description of the treatment (psychiatric diagnosis and treatment; psychotherapeutic treatment; hormonal treatment; specified surgical procedure; complications during treatment; necessary follow-up treatments; legal consequences such as name change and change of legal status); follow-up time (definition, e.g., since first examination, first surgical operation, last surgical operation, since name change and time elapsed); examination methods (Did the examiner participate in the treatment? How many examiners? Self-evaluation; evaluation by others; rate of agreement between self-evaluation and evaluation by others; number of examinations); situation of examination (within the scope of routine contacts; special post-examination session; in the patient's home; inclusion of partner, relatives, friends); instrument for examination (evaluation of treatment reports; questionnaires; telephone interviews; overall clinical impressions; unstructured, semi-standard or standard interviews; psychometric testing procedures; physical examinations and documentation); specific evaluation fields (e.g., need of psychiatric treatment; hospital admittance; mental shape; physical condition; social and professional stability; partnerships; sexual experiences); definition of evaluation criteria (e.g., relative - better, equal, worse; independent - very good, good, satisfactory, poor; self-evaluation or evaluation by others and the agreement or non-agreement thereof); indications about suicidal tendencies, role reversals or desires to return to original gender; case examples; recommendations for selection of patients; previous follow-up studies considered by the authors; results and golobal evaluations by the authors.

The reviews were, in principle, analyzed with the same criteria, whereby single aspects were given lesser importance and where methodological and ideological aspects discussed by the respective author(s) were given more importance.

Presentation of results
In the following presentation of the individual follow-up studies and reviews, which are listed chronologically by years and alphabetically within the years, we have included at the beginning and at the end a short text, presented in italics to indicate that it is our comment and not the original contents. In the texts' italicized introductions, we have indicated in keywords the formal assignments of the follow-up study or review and their importance for the general professional discussion, in accordance to our judgment. Here we also mention obvious sample duplications. In the italicized text at the end of each presentation that we have called "remarks," we have commented on single aspects and points of critique we think to be valuable. We are responsible for all these evaluations and not the cited authors.

We want to advise that in the presentation of results we diverge from the expressions used in every one of the original works as previously indicated and justified. We have oriented the gender definition at the follow-up date on how the (former) patients lived at that time. For patients not operated or not yet operated or who have returned to their original gender roles after surgery, we use in the tables the code T. In the left column is the code MFT, resp., females; in the right column is the code for FMT, resp., males.

The concept of the terminology used for surgical results has been discussed under the heading "Terminology" above. The concept regarding other treatment segments is, insofar as possible, simplified. Where hormonal treatments were used, we simply mention the word hormone. If not otherwise noted, females (MFT) received antiandrogens, and/or estrogens and/or gestagens. Males (FMT) received androgens. Any differentiation in regard to substances, medications and dosages was not deemed as useful, because most works contain little detailed information of same. For the same reasons, indications about psychological, psychotherapeutic or psychiatric treatments are not mentioned unless of particular importance.

The above-mentioned criteria under which the original works have been evaluated make it stand to reason that the results are represented in accordance to a standard scheme. To do so was our original intent, but soon we learned that the original works considered only a part of the named criteria. In most cases, too many of the items in the scheme would have been evaluated as being "no response." The announcement that a work contains no response to a certain item is important information, sometimes even the most important, but in the interest of the readability, it seems sensible to avoid the constant repetition of "no response." If the reader memorizes the evaluation criteria, the reader will notice what is missing in each of the original works. If there is, for example, a time of follow-up without a specific reference (e.g., since first examination, since first or last surgical operation), the original has no more specific indications. If it is not specifically mentioned that the author participated in the treatment of the post-examined patient or was independent to the operation, then one cannot discern anything about this in the original work. If complications during the operation are not discussed, it does not mean that these did not occur, but only that no useable data is contained in the report about it - unless the author(s) explicitly indicated that there were no complications.

The references to the item mentioned "previous follow-up studies" are only in regard to those cited in the original work that meet our criteria to report about five or more post-surgical transcourses. The exception to this rule is the mention of the single case report of Christine Jorgensen (Hamburger, et al., 1953) that was the initiator for the general occupation with the theme transsexualism. If the authors mention it, we have indicated it in the single follow-up studies but not in the reviews. Also in the reviews in the item mentioned "previous follow-up studies" we only regarded those works that met our criteria. Anyway, such references to this item do not show the number of other literature cited in the respective work. We only have taken this item to depict -- for us and the reader -- in what extent the authors worked with specific post-surgical reports and by that check the thesis of Springer (1979) of the citation circle. This is a formal check because the simple citing does not say anything about the magnitude of the research within the literature. Because of these thoughts we believed we had the right not to cite implicit-cited literature. An example for this implicit-citing is the inclusion of the book by Green & Money (1969) in a bibliography in that the specific work of Randell appeared without discussing Randell in any part of their text. In such not infrequent cases, we suppose that the incumbent authors have not analyzed Randell's work, that they possibly did not even know about it; so we cannot consider their statement.

To realize the specific characters of the works and the inclinations of authors, we recommend not to avoid reading the presentation of each individual work. A summarized presentation and evaluation will be done by us at the end.