From the Single Case Study to the Follow-Up Study

In the first half of this century there were only a few reports about sex reassignment surgery. As far as we know, Hirschfeld was the first reporting about this type of surgery, performed in 1912. "With masculine women the ... urge goes so far that they had their breasts amputated. I knew a 21-year-old girl who forced her doctors, a surgeon in connection with a psychiatrist, into fulfilling her wish" (Hirschfeld, 1918, Vol. II, p. 132, comp. Mühsam, 1926; Herrn, 1995; Pfäfflin, 1997). In the beginning there were very few physicians willing to fulfill the wishes of the patients who were called transvestites at the time. Basically it was agreed that this urge was of a pathological nature, independent of which type of ailment it was associated with. Mühsam (1926) and Abraham (1931) reported about such surgery in Berlin and Pokorny and Bondy (1933) about it in Prague. Most assuredly not all sex reassignment surgeries were reported about immediately. Walser's sample (1968) contains four people who were operated between 1932 and 1947, but it was not specified by whom, in which city or in which country these surgeries occurred.

During Nazi times in Germany the laws regarding homosexual behaviors were tightened and homosexuals, transvestites and transsexuals were interned in concentration camps. Despite this, at the same time, research activities and therapeutic support existed. Research, persecution and therapeutic philosophy sometimes entered into strange combinations; for example, there is a dissertation from the Institute of Forensic Medicine of the "Hansischen Universität" in Hamburg in which the author recommends hormonal and surgical sex reassignment procedures so "that the subjects go crazy with their predisposition and abandon their preferences easier" (Voss, 1938, p. 42). The author thought the "phenomena of transvestism" to be symptoms of a sick "popular body" and recommended to "exterminate it from public life" (p. 3); he believed "draconian measures by the government against stubborn and hard-headed transvestites are ... adequate." (p. 45) As a specific measure of prevention he recommended that castration should take place right after puberty and as other sanctions, permanent internment and preventive detention.

The tenor of a work published after the end of World War II on sex reassingment surgery performed between 1941 and 1943 in Hannover, Germany, with the help of a public health officer, is completely different: "As B. wanted to live as a woman and to reach a definite and humanely adequate solution all human (sic!) sexual organs were removed" (Huelke, 1949, p. 92). The result of the treatment was confirmed by the public health officer and concluded with the desired name change at the Registry Office. The collected clinical reports by Bürger-Prinz and Weigel (1940) differ from Voss' paradoxical thesis by seriously trying to understand people who do not feel at home in their bodies. A broad discussion was not prompted by all these reports.

A similar controversial discussion also initiated by psychoanalysts was held in the U.S.A. starting in 1954 (Ostow, 1953; Gutheil, 1954; Lukianowicz, 1959; Meerloo, 1967; Socarides, 1969; Kubie 1974; comp. Springer, 1981) as a reflex for the explicitly experimental case history of Christine Jorgensen, which was not only covered in print media but also on television (Hamburger et al., 1953; Jorgensen, 1967). In interchange with the media spectacle, the hormonal and surgical (castration) treatments conceived in the beginning only to dampen sexual urges in which vaginal surgery was not foreseen, were changed to sex reassignment surgery and perfected in this sense (Hertoft & Sörensen, 1979).

Pro and con arguments have been used in the following years until today in literature about transsexualism. Of note is that they were hardly discussed in follow-up studies literature. It seems as if there is no connection between the discussion which was initiated by singular cases and the realization of follow-up studies with larger samples.

Only a few follow-up studies specifically refer to this controversy and when they do, it is not in a way that deeply analyzes the theme. Hoenig et al. (1971), for example, mentioned a few authors who opposed sex reassignment surgery, but did not analyze their argumentation but rather declared globally that those who fundamentally disapprove of sex reassignments on moral or ethical grounds have no business doing follow-up studies. Because they themselves saw sex reassignment surgery as a useful therapeutic intervention, they considered follow-up examinations as necessary and were not interested in fundamental contrary arguments. Another author, Stürup (1976), who felt challenged by the criticism of Stoller (1972) that there were no follow-up studies, took up the challenge by presenting his follow-up studies without analyzing or discussing the fundamental objections of his "opponent."

More than ten years passed between the discussion in the publications in Psyche and the publication of the first follow-up study with more than five cases. It was from Sweden (Hertz et al., 1961) and it did not explicitly refer to the discussion among psychoanalysts in the Federal Republic of Germany and the United States. Due to the reservations by which the authors interpret their study results, it is somewhat questionable if the categorical declarations of the authors that there is no psychiatric therapy or that it has failed are a direct result of this controversy. Also in Sweden in 1963, and up till now still one of the very few, prospective studies was initiated (Wålinder, 1967). The controversy which occurred in other locations was not a theme. Additionally, from the patients he examined and treated, Wålinder has compiled a total of 207 descriptions of patients with transsexual symptoms. Apart from the review of Pauly (1965; 1974 a, b) whose diagnostic classification of many case studies of transsexualism were doubted by Springer (1981), in no other follow-up study has anyone ever taken the trouble to systematically compile and discuss single case studies or cases with small samples.

Until the mid-1960s, the first descriptions of bigger samples of follow-up courses were from the private practice of Benjamin. In the 1930s, he saw for the first time a patient who came for treatments for arthritis and who told him that he always had the urge to wear women's clothing. At the end of the 1940s Kinsey introduced the first patient with transsexual symptoms to him. Only after 1953 his practice changed from geriatrics and endocrinologic specialities to transsexualism. Because of the worldwide publicity about her operation, Christine Jorgensen sought out the cooperation of Benjamin because she could not handle the amount of correspondence (Schaefer, 1988). Benjamin could not cope with all requests either. He cooperated with the practice of the former Kinsey co-worker Wardell Pomeroy as well as with John Money and his disciple Richard Green of the Johns Hopkins University Clinic in Baltimore. Ideologically and financially they were supported by the Erickson Educational Foundation that supplied the finances for the work of the Harry Benjamin Foundation, founded in 1964.

More and more clinicians and researchers of different disciplines and qualifications began to take up the challenge of the increasing clientele and their treatment wish. They came from psycho-endocrinological, psychological, psychiatric and surgical specialities. What unified them was the apparently new, at least little noted, patient population that questioned the basics of the unchangeability and the untouchability of gender. While psychiatry was powerless regarding the desire of this clientele, the new treatment possibilities created omnipotent fantasies. Because the whole thing seemed to have something to do with sexuality and carried the amplifying name transsexualism, it fit well into the tendency of the time. In the U.S.A., the established sexual research under the aura of the sociographic works of the group of Alfred Kinsey opened an additional clinical field.

What also unified clinicians and researchers was the body-centered treatment and an anti-psychoanalytical emotion. It was specifically highlighted that the tennis star René Richards, who was, other than Christine Jorgensen, the most famous patient of Benjamin, had been in psychoanalytical treatment for eight years without making the transsexual symptoms disappear. Benjamin and Richards met for the first time in 1964 (Richards, 1988). In the later film based on her autobiography (Richards, 1983), in which Vanessa Redgrave played the principal role (I Changed My Life, 1986), the psychoanalytical treatment was analyzed as a soulless endeavor and contrasted to the empathic treatment by Benjamin. Green said about a meeting with René Richards, "My talks with Harry's patients educated me. One taught me the futility of psychanalytic therapy directed at reorienting sexual identity. This opthalmologist had had eight years of therapy when he consulted Harry for sex change ." (Green, 1988, p. 21)

Pioneer spirit and pragmatism defined the fast expansion of the new treatment technique. Because the fulfillment of wishes was promised, patients stormed in for treatment and there was little place or time for fundamental doubt. Any scientifically fruitful exchange between opponents and enthusiasts of the surgical procedure hardly took place. One of the few psychoanalysts who supported the program of gender identity clinics, Stoller, furnished the psychoanalytical legitimation for the somatic treatment by highlighting the difference between sex and gender and the postulation of a more-or-less fixed core gender identity (Stoller, 1968, 1973, 1975; comp. the criticism of Springer, 1981)

It is our impression that the circumstances that produced follow-up studies with bigger samples in the 1960s had more to do with general changes in the medical / psychological research than with the previously felt controversy about the pros and cons of sex reassignment surgery. During this time there was a general trend in psychological medicine that went from single case studies to cumulative case studies that were used, for example, by Binder (1933); Bürger-Prinz & Weigel (1940); Burchard (1961) and Bürger-Prinz et al. (1953, 1966) conducive to a description of groups and a statistical analysis of the data obtained. The single case study was denied medical proof value. The first follow-up study of operated TS patients with samples of five or more (for example, Hertz et al., 1961; Vogt, 1968) and the first reviews (Pauly, 1965, 1968) marked this transition. They were still cumulative case studies, but already questioned the general rules that could be learned from them.

Another important factor was the establishment of gender committees and gender identity clinics. They had to report their activities and account for their existence with their publications in accordance with the model of the Gender Identity Clinic of the Johns Hopkins University established in 1965 (Money & Schwarz, 1969) and the Gender Committee established at the University in Minnesota in Minneapolis in the following year (Hastings, 1969). Within the shortest time interdisciplinary teams joined in many places that grew into a more or less independent establishment that developed its own dynamics, as is usual with new branches of science. That follow-up studies were done is, in a matter of speaking, self-explanatory.

Only two of the later reviews tried to analyze the development of follow-up studies with systematic viewpoints. Lothstein (1982) introduced a chronological division in the 1970s by which he differentiated the different time periods in which, even though hardly convincingly, he tried to find the different evaluation focuses of authors. Abramowitz (1986), who only regarded a small number of follow-up studies, differentiated in pre-quantitative and quantitative works.

Intents to systemize are found in some follow up studies. McCauley and Ehrhardt (1984) took over the chronological division by Lothstein (1982) and related it to treatment results. They differentiated three phases. First, they counted works measuring with the criteria subjective satisfaction and social adaptation, where mostly positive results were reported (Benjamin, 1966; Money & Brennan, 1968; Pauly, 1968; Randell, 1969). In the second phase, they counted, besides the positive the negative results and exceeding that, they highlighted that marked psychopathies are only influenced by surgery in a minor way. For this second phase, the works of Hastings & Blum (1967); Hoenig et al. (1971); Money & Ehrhardt (1970); Stürup (1976) as well as Wålinder & Thuwe (1975) were considered. In the third phase (Hunt & Hampson, 1980 b; Lothstein, 1980; Meyer & Reter, 1979; Sörensen, 1981a) the earlier reported positive results were affirmed by the subjective satisfaction. Measured in social, psychiatric and economic criteria, the improvement was less marked.

Another division was elected by Simona-Politta (1983) that formally differentiated between descriptive and evaluative works. This division partially overlapped with the pre-quantitative and quantitative works selected by Abramowitz (1986) that was later adapted by Dudle (1989).

The follow-up study research about sex reassignment surgery represents a partial aspect of a bigger field of research, which is the research of the effectiveness of therapeutic treatments. This is why it is to be expected that other fields within this larger frame have also changed their queries about methodical procedure and interpretation of results and that forces comparisons among the other fields. Meyer et al. (1991) have given an overview about the research works as to the effectiveness of psychotherapy in general in their study called Expertise and reaserch review on psychotherapy outcome in the debate for a law for psychotherapy (Forschungsgutachten zu Fragen eines Psychotherapeutengesetzes) made for the (German) Federal Ministry of Youth, Family, Women and Health. This is not in relation to specific methods or a certain group of patients. The four research phases developed show notable parallels to the research of follow-up studies about sex reassignment surgery: The authors described an early phase that was marked by single case studies with comparisons of feelings, symptoms, behavior, etc., of single patients before the start of and at the end of psychotherapy. The second phase started with Eysencks' (1952) demand for control group studies to differentiate between treatment effects and spontaneous remissions, called the phase of proof and justification by the authors. In it, it was tried to prove by statistical procedures that psychotherapy is effective. Only in the third phase, which cannot be separated in a time aspect, different therapy methods, therapy settings, therapy recommendations and so on, were compared one with another. This led to a differential psychotherapy research. In this third phase aspects of justification played an important role, but additionally, important questions such as the differential indication, process variables, economic viability, etc. were analyzed. The newest phase is marked by meta-analytical studies and the goal to research the specific effects of the therapy methods or variables.

If one uses this division within literature about the effectiveness of sex reassignment surgery, then meta-analytical works do not exist. At least one cannot call the reviews published so far this. In the category of differential therapy effectiveness research, only a few works (for example, Kando, 1973; Lothstein, 1980; Lundström, 1981; Sörensen, 1981 a; McCauley & Ehrhardt, 1984; Blanchard et al., 1985; Mate-Kole et al., 1990) qualify. Most follow-up studies belong to that division termed by Meyer et al. (1991) the phase of proof and justification. Single case studies that are characteristic for the early phase are found -- as previously cited -- also in research reports about sex reassignment surgery. In accordance with our criteria for the selection of follow-up studies that report about at least five patients, they are not considered here, even if we have to say limiting that some of the works cited by us are -- as already mentioned -- cumulative case studies (for example, Hertz et al, 1961; Vogt, 1968).

The comparison with the overview of Meyer et al. (1991) in which 4000 controlled studies as to the effectiveness of psychotherapeutic methods of different psychotherapeutic procedures published during the last 40 years containing different syndromes are compiled, is rewarding in another manner: Even though the total numbers of treated patients -- either for psychotherapy or patients for sex reassignment surgery -- cannot be determined exactly, there is no doubt that the numbers of psychotherapy patients are many tenth powers higher than the number of the TS patients. The comparison of the relation between treated patients and the systematically follow-up studied patients results that patients after sex reassignment surgery are at a higher value than psychotherapy patients and this denies the always-published statement that the effectiveness of the specific treatment in relation to a sex reassignment surgery has not been studied or not been studied enough.