Pauly, 1968
Dept. of Psychiatry, University of Oregon Medical School, Portland, OR, USA

In this overview the author compared the data of his own literature publications of his first hundred published cases of MFTs (Pauly, 1963, 1965) with the data of Benjamin's monograph (Benjamin, 1966), resp., the short version of the results reported about there (Benjamin, 1967).

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

*The publications about FM-transsexualism were in preparation; the publication does not contain further statements about this sample; the corresponding data was published six years later (see Pauly, 1974a, b)

**Pauly (1963) was a predecessor of Pauly (1965) presented at the Annual Meeting of the American Psychiatric Association, 1963, St. Louis. The author could not exclude that his sample overlapped with that of Benjamin's.

***The mean age was at the time of first surgery 32.2 years (range 19-58; the mean value corresponds to the one mentioned in Pauly [1965]; the range diverges noticeably). The follow-up times measures since the first surgery range from three months to 13 years, with a mean of five years (comp. the statement in Pauly [1965]: according to which the follow-up time for the sample included here range from six months to 25 years).

Evaluation Fields and Criteria
The results of surgery were categorized as follows: satisfactory: good emotional and social adjustment as well as subjective satisfaction of the patient with the surgical results; unsatisfactory: either the post-surgical adjustment of the patient was worse than before or the patient was dissatisfied and in retrospect would not have undergone surgery; uncertain: insufficient or contradictory statements, or further surgery wishes and no sexual functioning capability.

In Pauly's series the portion of uncertain results is relatively high, with 46%, disregarding the circumstance primary authors generally spoke of favorable results. Where this could not be fathomed, the author decided on the category uncertain. The categories "good" and "satisfactory" used by Benjamin were compiled by Pauly to facilitate the comparability.

Follow-up Studies Mentioned
Benjamin, 1966, 1967; Hamburger et al., 1953; Hertz et al., 1961; Pauly, 1965; Wålinder, 1967

Author's Conclusions
"However cautiously one interprets the results, it would appear that a satisfactory outcome to the sex reassignment surgery, in terms of improved social and emotional adjustment, is at least 10 times more likely than an unsatisfactory outcome. There is no claim that the transsexual is free from emotional conflict either before or after the procedure, but in the majority of instances he is markedly improved" (p. 465).
In view of the FMTs hormone treatments and surgical procedures are just as helpful as for MFTs. The physician who starts a hormone treatment must be, in principle, ready to support the surgical procedure. It is not adequate, for example, just to be for penectomy and castration and not for a vaginoplasty - as is constantly happening.

Indication Recommendations
(1) Psychiatric examination to determine if the gender dysphoria is permanent and irreversible and not the symptom of an acute psychosis.

(2) The physical appearance and behavior should demonstrate that the subject gets along in the other gender role and is accepted in it.

(3) Sufficient intelligence to comprehend the limits and possible complications of surgery.

(4) The readiness to participate in the pre-surgical diagnosis and the long-term follow-up study.

(5) An agreement not to sue the physician and the clinic or obtain material gain from the procedure by organizing a big media circus.

Remarks
This publication is a decisive position for the sex reassignment surgery. The author categorically declares that psychotherapy has failed in the attempt to help patients with transsexual symptoms to reconcile with their physical disposition, and that there are no alternatives to surgical treatments. Psychotherapy is very useful in as far as it is a support to the new gender role.

Besides this, the publication contains remarks about the establishment of the Gender Identity Clinics of the Johns Hopkins University Clinic in Baltimore, MD, at the University School of California at Los Angeles and at the University of Minnesota Medical School in Minneapolis. It also reports about a change of mind within the US-American medical groups regarding sex reassignment surgery.