Sex Reassignment Surgery: Historical,
Bioethical, and Theoretical Issues 
 By Leslie M. Lothstein, Ph.D. 

   The reported 68% - 86% overall success rates for sex reassignment surgery 
must be viewed cautiously; the lack of long-term follow-up studies makes these 
statistics misleading.  There is evidence suggesting that some gender 
dysphoric patients benefit primarily from sex reassignment surgery.  Most such 
patients, however, are secondary transsexuals who can benefit from various 
modes of psychotherapy.  Sex reassignment surgery should only be considered as 
the last resort for a highly select group of diagnosed gender dysphoric 
patients.  As physicians learn new ways to diagnose and treat transsexualism, 
either sex reassignment surgery will be abandoned as a routine treatment 
modality or new predictive variables for choosing suitable patients for sex 
reassignment surgery will be established. 
   Received Oct. 10, 1980; accepted Dec. 23, 1980. 
   From the Department of Psychiatry, University Hospitals of Cleveland 
Address reprint requests to Dr. Lothstein, University Hospitals of Cleveland, 
2040 Abingdon Rd., Cleveland, OH 44106. 
   Few psychiatric issues have stirred up as much controversy and emotional 
turmoil as transsexualism and sex reassignment surgery.  Those clinicians who 
espouse sex reassignment surgery as a legitimate form of treatment view it 
either as a palliative or a cure of the gender dysphoric patient's intense 
social-psychological suffering.  Most clinicians who recommend sex 
reassignment surgery as the treatment of choice also tend to believe that 
psychotherapy is useless with gender dysphoric patients.  In support of their 
view, they cite several positive follow-up studies on postoperative 
transsexuals (1-3) and the American Medical Association Commission on Human 
Sexuality's 1972 sanction of sex reassignment surgery as the treatment of 
choice for diagnosed transsexuals (4).  Moreover, a recent book, Controversy 
in Psychiatry, mentioned sex reassignment surgery as a viable treatment 
modality for selected patients in a medical center (5). 
   On the other hand, those clinicians who consider sex reassignment surgery 
as an illegitimate form of medical-surgical treatment usually characterize it 
as mutilative and antitherapeutic.  They point to the complex psychological, 
medical, legal, bioethical, and political issues that are neglected or 
bypassed by sex reassignment surgery procedures.  They argue that sex 
reassignment surgery leads to mistreatment and mismanagement of the gender 
dysphoric patient.  In one study a majority of the 300 physicians queried 
opposed sex reassignment surgery for transsexuals (6).  In support of their 
view, clinicians cite studies indicating that various modes of psychotherapy 
can successfully stabilize the gender dysphoric patient short of sex 
reassignment surgery (7-9).  These studies suggest that some clinicians may 
have prematurely accepted Hertz and associates' dictum that "transvestism [now 
called transsexualism] resists psychiatric treatment" (10). 
   The debate among mental health practitioners has recently been fueled by 
the closing of the Johns Hopkins Gender Identity Clinic (11) and by several 
studies supporting sex reassignment surgery (reference 12 and an unpublished 
study by S. Satterfield).  Arguments both for and against sex reassignment 
surgery, however, are based more on rhetoric than on hard evidence.  Those who 
believe sex reassignment surgery is beneficial for certain patients must 
acknowledge the lack of hard empirical evidence supporting their views and the 
lack of even acceptable diagnostic criteria for selecting good candidates for 
sex reassignment surgery.  Those who argue against sex reassignment surgery 
must account for the reported wide spread patient satisfaction with the 
procedures and evidence of resulting positive life changes.  While DSM-III 
addresses some of the confusing diagnostic issues among the gender identity 
disorders, the new criteria do not deal with treatment issues.  In addition 
there are no standards for the medical-psychological care of patients with 
profound gender dysphoria (transsexualism).  As more and more patients request 
sex reassignment surgery, the issue of appropriate treatment for them becomes 
central.  Indeed, ever since the sensationalism of the Christine Jorgenson 
case (13), large numbers of patients have requested information regarding sex 
change (14, 15).  A combination of several factors - the availability of 
surgery, media exposure, the existence of national and international referral 
centers and information sources, and the establishment of many gender identity 
clinics - has made it necessary for clinicians to take a stand for or against 
sex reassignment surgery. 
   Of the currently estimated 30,000 transsexuals, as many as 10,000 may be 
residing in the United States (16).  One researcher, Prince (17), has even 
suggested that the number of requests for sex reassignment surgery has reached 
epidemic proportions.  Indeed, a 1977 report estimated that over 1,000 
surgical procedures would be performed in the United States in 1980 (16).  As 
long as there are no universally accepted standards of care, hospitals can 
either prohibit sex reassignment surgery or make it routinely available to 
gender dysphoric patients on a fee-for-service basis.  If sex reassignment 
surgery becomes a Medicaid-subsidized procedure, it could be performed on many 
nontranssexual patients with gender dysphoria, who may later regret their 
decisions.  While all practitioners should be concerned about the unrestricted 
use of sex reassignment surgery, it may be that for some patients sex 
reassignment surgery is the treatment of choice.  Those clinicians who espouse 
sex reassignment surgery, however, must determine which gender dysphoric 
patients are the best candidates for the procedure. 
   In spite of the many clinical research studies of transsexualism, very 
little is actually known about the medical-surgical and social-psychological 
effects of sex reassignment surgery.  Many questions are left unanswered.  For 
example, which, if any, patients derive the most benefit from sex reassignment 
surgery?  What data support the continued use of sex reassignment surgery as a 
treatment regimen?  What is the crucial test for determining the prescription 
of sex reassignment surgery? 
   To my knowledge there has not been a single comprehensive review of the 
published sex reassignment studies or an analysis of their results.  It is the 
aim of this paper to address these issues by reviewing and examining the 
historical roots, assumptions, and findings of the major studies.  In this 
context, suggestions for future research strategies and directions for 
treatment will be made. 
   The historical, cultural, anthropological, and literary development of 
sexual transformation and surgery is well documented (18-21).  Green (22) 
cited incidences of sexual transformation procedures in early Greek and 
classical history, the Renaissance, and modern times: cultural examples from 
American Indian tribes as well as Indo-European and Asiatic cultures are 
included.  Throughout history instances of autocastration and genital 
mutilation, the result of an individual's intense desire to change sex have 
been reported (23).  Translating the desire for sex reassignment surgery into 
a reality, however, required the advances of modern surgical technology and 
hormonal procedures.  In the following reviews of surgery follow-up, the 
studies are reported chronologically. 
   While Abraham (24) reported on the first sex reassignment surgery of two 
male transvestites in 1931, it was not until the publication of Lilly Elbe's 
autobiography (25) that sex reassignment surgery became a popular and 
practical solution for the transsexual's dilemma. 
   The first significant postsurgical findings were reported by Hertz and 
associates (10).  That study investigated the postsurgical functioning of 2 
male and 3 female transvestites (including one who changed back to his male 
role after 7 years).  The mean postsurgical period was 7.8 years (range = 3.5 
to 16 years).  Follow-up data on 4 patients' social-emotional states suggested 
satisfactory outcome.  The evaluative criteria were based on the impressions 
of the investigators.  A review of the findings suggests some discrepancies 
with usual clinical assessment in that one patient who was judged to have a 
satisfactory outcome was actually a depressed drug addict who engaged in 
homosexual prostitution. 
   The beginning of serious research in the field was initiated with the 
publication of Benjamin's classic follow-up study (1) of postoperative 
transsexuals.  Of 73 men and 20 women who underwent surgery, 85% of the men (N 
= 62) and 95% of the women (N = 19) showed satisfactory outcomes.  These 
figures were derived by classifying postsurgical patients into three 
categories: unsatisfactory, good, and satisfactory.  The assignments were 
based on impressionistic evidence, patients' self-reports, and anecdotal 
material about the patients' postsurgical social-biological-psychological 
status.  There were no attempts to obtain standardized data from each patient; 
no demographic data were provided.  The overall 87% improvement figure 
included patients in both the good and satisfactory groups. 
   Money and Brennan's study (26) of 6 postsurgical women corroborated 
Benjamin's findings.  They concluded that "the evidence to date is that sex 
reassignment does indeed improve the human condition of the afflicted 
individual."  However, neither of these studies separated the male and female 
groups on any basis whatsoever.  Since most theoreticians regard female 
transsexualism as diagnostically and dynamically distinct from male 
transsexualism (27), one would expect that such a methodological error could 
lead to faulty conclusions. 
   In his 1968 review (28) of the world literature on 121 cases, Pauly 
concluded that a group of transsexuals who underwent sex reassignment surgery 
was 10 times more likely to have a satisfactory outcome, in terms of social 
and emotional status, than a group who did not.  These findings have provided 
the bedrock for continued support of sex reassignment surgery. 
   Randell (2) reported postoperative results on 29 men and 6 women 
(postsurgical follow-up ranged from 3 months to 7 years).  According to the 
male and female adjustment ratings (including acceptability as a male or 
female, subjective satisfaction, social adaptation, and physician's 
assessment), 72% of the men and 83% of the women had satisfactory outcomes.  
Although 2 men committed suicide, Randell concluded that the patients 
demonstrated lessened environmental conflicts, significantly decreased levels 
of anxiety and depression, and improvements in family relations and 
   The studies of the 1960s ended on a less positive note as Golosow and 
Weitzman (29) reported on a single case involving a man who was hospitalized 
with severe depression and regressed behavior 15 months after sex reassignment 
surgery.  The patient had been provided with sexual surgery despite the lack 
of a life long gender conflict.  Benjamin (1) had previously described a case 
of a 56-year-old man who expressed regret after surgery and was later 
reassigned back to his male role. 
   Money and Primrose (30) reported that none of their 12 postoperative male 
transsexuals exhibited a maternal response.  This finding was amplified by 
Newman and Stoller (31), who hypothesized that male transsexuals are not 
capable of achieving womanhood, since they have not experienced the usual 
developmental pathways and oedipal conflicts of biological girls and only 
exhibit surface-shallow female characteristics.  They concluded that although 
surgery may change a person's secondary sexual characteristics, the inner male 
or female identity remains untouched.  Unfortunately, no further analyses of 
the inner psychological feelings of postoperative transsexuals were performed. 
   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 (32). 
   Throughout the 1970s increasing numbers of patients sought sex reassignment 
surgery.  Many of these patients were secondary transsexuals who, under 
stress, expressed a regressive wish for sex reassignment surgery.  Spurred on 
by changing views of societal sex roles, large numbers of patients were given 
external support to change their sex rather than to understand the nature of 
their psychological distress.  Moreover, lacking a formal schema to diagnose 
gender dysphoric conflicts and lacking standards of medical-surgical care, the 
profession of psychiatry was unprepared to adequately respond to the 
transsexual's dilemma.  In addition, since sex reassignment surgery was 
available to almost any self-labeled transsexual who could pay the fee and the 
surgery was often performed secretly, few of them were available for follow-
up.  There was little that psychodynamically oriented psychotherapists could 
do to intervene using psychological methods. 
   In spite of the many difficulties outlined, the initial studies of the 
results of sex reassignment surgery in the 1970s widened the criteria for 
investigating the postsurgery patient and contributed significantly to 
advances in our knowledge of gender identity disturbances. 
   In the apparently first published study of the 1970s, Money and Ehrhardt 
(33) investigated 17 men and 7 women and compared the patients' preoperative 
and postoperative adjustment along five dimensions: capacity for a lasting 
relationship with a partner, adjustment to work, criminality, mental state, 
and patients' subjective opinion of the result.  Only one woman was reportedly 
dissatisfied with the cosmetic results, but she stated that she would undergo 
the procedure again.  The patients' satisfactory adjustment on all levels led 
to the conclusion, "If one is able to stipulate specific criteria for sex 
reassignment surgery, then it can be seen that the outcome of sex change, that 
is, the psychological and social situation of transsexuals, is oftentimes 
better than worse" [my translation].  The conclusion was somewhat illusory in 
that no universally acceptable criteria for patient selection were provided.  
   In the second study of the 1970s, Hoenig and associates (34) reviewed the 
literature on sex reassignment surgery and reported on a follow-up study of 8 
of their own patients (5 men and 3 women).  One of the women and 4 of the men 
were judged to be psychiatrically disturbed; 1 of the men had had a leucotomy.  
Although 1 patient was judged to have a poor outcome, none of the patients 
expressed regret over the surgery.  The 12% failure rate supported the 
authors' conclusion that "the treatment helps the majority of patients both 
subjectively and objectively... but the operation can in no sense be regarded 
as a cure."  This was the first study to acknowledge the high incidence of 
psycho-pathology among postoperative transsexuals and challenged the notion 
that sex reassignment surgery could cure the transsexual's distress.  Indeed, 
2 years later Money and Wolff (35) reported on a male transsexual whose 
postoperative depression was so severe that he was later reassigned to his 
male role.  They attributed the poor results to a deficient presurgical 
evaluation.  The possibility of surgery's proving harmful has been supported 
by a number of single case studies (36-38).     
   At Northwestern Medical Center Arieff (39) studied 14 men and 4 women for 5 
years after surgery.  The group included 3 blacks and 1 Oriental.  Nine 
patients (50%) demonstrated better social adjustment; 2 patients (11%) had 
better vocational adjustment; 5 (28%) improved their relationships by getting 
married; and overall conditions worsened for 2 patients (11%).  While the 
amount of overlap among the groups is unclear, it is apparent that the 
majority of patients were not cured. 
   While Gandy (40) supported the use of objective criteria to assess outcome 
(social and economic improvement and subjective feeling of happiness), his 
report of the preliminary findings of the Stanford group indicated that 
surgery on demand would probably be disastrous.  Unfortunately, he did not 
elaborate on this view. 
   On the other hand, Ihlenfeld's review (41) of Benjamin's findings indicated 
that most adult transsexuals achieved good results with sex reassignment 
surgery (although 5 of the patients died from mysterious drug-related 
accidents).  Ihlenfeld's optimism about sex reassignment surgery led him to 
argue for the possible surgical benefits for transsexual patients in their 50s 
and 60s. 
   Hastings and Blum (42) reported on 25 men who received sex reassignment 
surgery at the University of Minnesota.  Using a college grading system (A, B, 
C, and D), they rated patient outcome on sexual, economic, and social 
variables.  Twelve patients experienced multiple orgasms; 12 patients were 
marginally self-supportive; 8 were on welfare; 10 patients were married, 
including 6 who had remained with their original spouses.  Despite 1 who 
attempted suicide, satisfactory adjustment was reported for all the patients.  
There was no indication of the degree of overlap among the variables of change 
investigated.  One case warrants reporting in detail because of its 
consequences.  In that case a patient who mutilated his genitals and had a 
prison record was eliminated as a surgical candidate.  The patient's threat of 
suicide, however, prompted Hastings and Blum to bring in six outside judges 
from Minneapolis.  The judges urged the clinic to perform surgery: 1 month 
after surgery the patient reverted to living as a man.  In another instance 
one of their clinic staff members recommended 5 psychopaths for sex 
reassignment surgery to see if this procedure would cure their character 
problems.  He eventually concluded that sex reassignment surgery is not a cure 
for psychopathy. 
   Laub and Fisk (43) reported on 74 patients - 50 men and 24 women - who 
received sex reassignment surgery.  (At the 1980 APA annual meeting the 
Stanford team updated their statistics, reporting that 131 men received 
vaginoplasty, 75 women received phalloplasty, and 86 women received 
mastectomies.) Thirty-eight of the men had surgery at Stanford.  They 
evaluated patients' employment, social-psychological, and sexual adjustment 
using a grading system similar; to that used by Hastings and Blum.  Five 
patients were unavailable for follow-up.  Although 1 patient regretted having 
surgery and another committed suicide, they concluded that sex reassignment 
surgery did not significantly harm any patients.  They reported significant 
improvement in all but the psychological areas of functioning.  This study is 
important because the surgical group included nontranssexuals, e.g., 
effeminate homosexuals and transvestites, and the researchers separated the 
psychological from the social domain.  The term "gender dysphoria syndrome" 
was used to describe patients who requested sex reassignment surgery.  Laub 
and Fisk concluded that "transsexuals are not the only group that can benefit 
from this type of surgery."  Preoperative behavioral adaptation to the new 
gender role, not psychiatric diagnosis, was found to be the best predictor of 
postsurgery outcome.  This was apparently the first study that mentioned sex 
reassignment surgery as a treatment for nontranssexual disorders. 
   At the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome, 
Fisk (44) reported on the postsurgical follow-up of eight men who had been 
diagnosed as psychotic or schizophrenic (with delusions focusing on sexual 
identity).  Their postoperative improvement was so marked that Fisk labeled 
them "eight spectacular cases"; the number has recently been reduced to 5 
(45).  Fisk felt that sex reassignment surgery could result in remission for 
some psychotic or schizophrenic individuals whose disturbances focused mainly 
on sexual identity.  Prior to this report, all surgical centers had refused to 
operate on schizophrenic or psychotic patients.  Schizophrenic patients with 
delusions of sex change had been known to request sex reassignment surgery 
(46).  The suggestion that sex reassignment surgery might prove beneficial for 
schizophrenic patients represented a major departure from current thinking. 
   Gottleib (47) reported on the follow-up of 9 transsexuals, including 1 who 
was left decorticate secondary to anesthesia, 1 who was postoperatively 
labeled a "freak," and a 23-year-old male-to-female patient who adopted a 
lesbian role after surgery.  Biber (48) reported on 1 schizoid patient who was 
in the process of being reassigned back to his biological maleness.  In light 
of these poor outcomes, a well-known author and transvestite, Virginia Prince, 
suggested that more attention be paid to nonsurgical alternatives for 
transsexuals, noting that, at least in California, "sex reassignment surgery 
is a communicable disease" (personal communication, 1977). 
   Hore and associates (49) reported on 16 English transsexuals who were 
studied for 6 to 18 months after surgery.  For 11 patients (69%) the surgery 
was judged beneficial, i.e., they felt more feminine, had increased 
confidence, and were emotionally and sexually better adjusted; 2 of them 
married.  However, 5 patients expressed dissatisfaction; 3 were dissatisfied 
with the cosmetic results, and 2 did not feel completely female.  Eight of the 
11 patients (73%) had long histories of psychiatric illness.  These results 
were consistent with the findings of Hoenig and associates (34). 
   Money (50) reported on one of the youngest patients to have sex 
reassignment surgery.  The patient was a male twin whose penis had been 
amputated secondary to an accident during circumcision.  The child was 
surgically revised to a female at age 17 months and is being raised as a girl.  
Recent follow-up suggests a good outcome. 
   In a study conducted at Vanderbilt University, McKee (51) reported on 7 men 
and 4 women who had received surgery but did not provide detailed notes on 
their social-psychological condition. 
   Walinder and Thuwe (3) conducted the most comprehensive follow-up study to 
date.  They examined the social-psychiatric histories of 24 reassigned 
transsexuals; detailed histories for each patient were included in the report.  
Eleven men and 11 women were available for follow-up; 2 men were not.  They 
expanded on Money and Ehrhardt's five follow-up criteria (33) by elaborating 
on the social aspects, e.g., place of residence, Social Security benefits, 
alcoholism, criminality, periods of certified sickness, and disability 
pensions.  Other adjustment criteria included sexual life (propensity and 
strength), housing conditions, attitudes of relatives, work records, patients' 
subjective opinion, and investigators' assessment (including psychological 
state and appearance).  By studying their patients at least 3 years 
postoperatively, they tried to eliminate the usual immediate postsurgery halo 
effect.  They found that the biological females generally had a better 
outcome; 2 men (18% of the men) regretted having surgery.  Overall, 91% of the 
women and 69% of the men had satisfactory outcomes.  These results are 
consistent with those of Benjamin (1), Randell (2), and Money and Ehrhardt 
(33).  The small sample size precluded the possibility of obtaining 
statistically significant presurgery and postsurgery differences.  Walinder 
and Thuwe concluded, 
   Taking men and women together, the outcome was clearly favorable in 
approximately 80% of the cases.  The proportion of unsuccessful cases in our 
series is about the same as that found by Hoenig et al in a review of 
previously published follow-up cases.  When we considered the severe suffering 
and the many difficulties experienced by untreated transsexuals in various 
fields of life, the treatment programme appears to be fully justified both 
medically and ethically. 
   Sturup (52) clinically evaluated 8 of 10 patients up to 19 years after sex 
reassignment surgery.  Two had died; half of the remaining patients exhibited 
severe adjustment problems.  All but 1 reported psychological problems, 
including difficulty at work, sexual maladjustment, depressive ideation, 
suicidal behavior, familial rejection, continuous living in the male role, and 
reactive psychosis.  In spite of these difficulties, all of the patients were 
satisfied with the surgical results. 
   Lothstein (53) studied two groups of patients after sex reassignment 
surgery.  Group 1, consisting of 7 biological males, had sex reassignment 
surgery before the establishment of a gender identity clinic at Case Western 
Reserve University Medical School.  Group 11 (8 biological males and 6 
biological females) had surgery after intensive evaluation and long-term 
psychological and medical treatment.  The average postsurgery time span was 
1.9 years (range = 0.5 to 3.5 years).  Systematic data were gathered on each 
patient in group 11 prior to surgery.  Patients completed a 59-item 
questionnaire focusing on sexual, psychological, environmental, economic, 
parental, family, medical, and social adjustment and functioning.  This was 
apparently the first research study in which patient data were systematically 
collected and each patient was required to participate in intensive 
psychological treatment. 
   The results suggested moderate postsurgical social and sexual gains 
accompanied by marked depression and psychological confusion.  However, all 
patients reported being subjectively satisfied with the surgery.  It was 
concluded that character structure and neurotic functioning are not 
permanently altered by sex reassignment surgery.  Moreover, all patients 
should be routinely provided counseling and/or psychotherapy to help them 
adjust to their new social-psychological status.  Sex reassignment surgery 
does not facilitate the patient's psychological integration of gender role and 
identity; this integration requires psychotherapy.  A major conclusion of this 
study was that all preoperative and postoperative gender dysphoric patients 
should undergo psychotherapy. 
   In the most controversial study, Meyer and Reter (11) studied 100 patients 
who applied for sex reassignment surgery at the Johns Hopkins Gender Identity 
Clinic.  Of these, 34 underwent surgery (24 at Johns Hopkins and 10 elsewhere) 
and 66 failed to qualify for surgery.  Only 15 of the 34 surgery patients (44% 
of the sample) were available for follow-up, 17 were lost to follow-up and 2 
refused to participate.  Of the 66 nonsurgery patients (the control group), 35 
(53%) were available for follow-up and 31 were lost to follow-up.  In summary, 
only 50% of the 100 patients were available for follow-up.  Fourteen of the 35 
nonsurgery patients later received surgery, including 5 patients at Johns 
Hopkins; the remaining 21 patients were still interested in obtaining surgery.  
The surgery group (average age = 30 years) was studied for a mean of 5.0 years 
(range = 19-142 months); the nonsurgery group was followed for 2 years (range 
= 15-48 months).  Four blacks were included in the group. 
   Since there was no breakdown according to socioeconomic status, education, 
and race, the effect of interaction among these variables is unknown.  All 
data except years of schooling were reported in percentages.  The measured 
variables included change of residence; job and educational levels; prior 
psychiatric treatment; and overall assessment score derived by using an 
arbitrary scaling method on legal, economic, marriage, cohabitation, and 
psychiatric histories.  Psychotherapy was not provided, and there was little 
information on psychological functioning.  While there were no statistically 
significant differences among the initial adjustment categories, the trends 
did suggest that the surgery group showed the greatest changes over time.  
This finding was not elaborated on.  Meyer and Reter concluded that "sex 
reassignment surgery confers no objective advantage in terms of social 
rehabilitation although it remains subjectively satisfying to those who have 
rigorously pursued the trial period and who have undergone it."  As a result 
of a press release, these findings were used as evidence to close the surgical 
program at Johns Hopkins.  In the last analysis, the decision seemed to be the 
result of political pressure and not to be based on the empirical findings of 
the study. 
   Hunt and Hampson (12) reported on the follow-up of 17 biological males 
(mean of 8.2 years after surgery).  While the patients reported gains in 
sexual satisfaction, family acceptance, economic functioning, and 
interpersonal relationships, there were no changes in the incidence of 
psychopathology.  Although none of the patients regretted having the initial 
surgery, 24% still felt a "driven need for further surgical procedures."  The 
authors concluded that for a select group of transsexuals, "surgery will 
continue to offer... the best means of coping with this dilemma."  They 
cautioned, however, that sex reassignment surgery does not alter personality; 
the best predictors of postsurgical success are presurgical ego strength and 
patients' "adjustment during the presurgery period while living in their new 
gender/sex role." 
   At the 1980 APA annual meeting in San Francisco, Satterfield (unpublished 
study) reported the preliminary findings of a follow-up of the original group 
described by Hastings and Blum.  The 22 postoperative transsexuals included 3 
female-to-male patients (average postsurgery period = 3.8 years) and 19 male-
to-female patients (average postsurgery period = 9.2 years).  All patients 
agreed to the interview and assessment and gave favorable responses about the 
surgery on the structured interview and psychological assessment tasks.  
Patients were physically examined by a psychiatrist also trained in plastic 
surgery, were given a battery of psychological tests including the MMPI, SCL-
90, and Zung depression inventory, and were asked to complete an elaborate 
questionnaire.  Whenever possible, material from hospital charts and therapy 
notes was used.  None of the patients expressed regrets about having surgery, 
and all showed "a significant improvement in psychological functioning."  A 
global measure of improvement was derived based on responses to interview 
material and psychometric testing.  The minimal presurgery screening in the 
original program made it necessary to base many of the conclusions on post hoc 
analysis.  The relationship between quality of surgical results and good 
psychological functioning was found to be statistically significant among 16 
patients who changed from male to female (p < .01). 
   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.  Sturup (52) supported this idea, noting, "In 
some of the early cases the reluctance on the part of therapists to adopt an 
active therapy [had] been too great." 
   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. 
   Methodological Problems of Follow-Up Studies 
   Most of the 785 postsurgical patients (approximately 596 men and 189 women) 
who have been studied are self-selected; they have voluntarily enrolled in a 
hospital- or university-based gender identity clinic.  Their intense 
surveillance includes an extended psychological and behavioral evaluation that 
often lasts over 1 year.  A review of follow-up studies suggests that gender 
clinics' surgical requirements can be met only by patients who can cope with 
delayed gratification and frustration; they may even be somewhat passive and 
compliant.  However, these patients represent only a small percentage of the 
estimated 30,000 self-labeled transsexuals, of whom 3,000-10,000 have 
reportedly received sex reassignment surgery.  The vast majority of gender 
dysphoric patients obtain sex reassignment surgery on a fee-for-service basis 
without benefit of a prolonged diagnostic evaluation.  As a group they are 
probably more impulsive, impatient, anxious, and demanding of sex reassignment 
surgery than are those who enroll in university-based clinics.  Many of these 
patients are probably secondary transsexuals who feel surgery will relieve 
their emotional distress.  Unless these patients need additional surgery, they 
will be generally unavailable for follow-up.  The lack of baseline data on 
their presurgical psychological states makes it impossible to evaluate the 
changes caused by sex reassignment surgery.  More over, neither the surgeons 
who perform sex reassignment surgery on demand or their patients seem to be 
interested in understanding the psychological roots of transsexualism. 
   In order to apply the results of these follow-up studies to the wider group 
of postsurgical transsexuals, we must determine whether those who have been 
studied represent an adequate cross-section of all sex reassignment surgery 
patients.  If not, this sampling bias is a primary methodological problem 
inherent in all of the published studies on sex reassignment surgery.  A 
review of those studies reveals other serious methodological problems, 
including a lack of universally accepted criteria for diagnosing gender 
dysphoria and determining suitable candidates for sex reassignment surgery; 
lack of an adequate control group; considerable variability among programs in 
gender identity clinics as well as in the quality, training, and experience of 
clinical staff; failure to include basic data on patients' race and age; 
frequent use of nonoperationalized criteria for improvement, such as patients' 
subjective feelings of happiness; use of college grade level systems for 
evaluating outcome; failure to provide data on the length of time between 
evaluation, surgery, and follow-up; failure to use uniform diagnostic labels; 
failure to use standardized clinical instruments to assess patients, even 
within a single study; limitation of clinical investigation to gross, social-
psychological variables; failure to include in-depth psychological analysis; 
use of hypothetical post hoc analyses to provide missing presurgical data; and 
use of biased evaluators to interpret outcome data.  This list is by no means 
   These methodological difficulties can be addressed by providing all sex 
reassignment surgery patients with uniform clinical interviewing, questioning, 
evaluation, and treatment schedules and follow-up questionnaires.  To date 
only one follow-up study has attempted to fulfill some of these requirements 
(53).  While there are still no uniform criteria for patient selection for sex 
reassignment surgery, the Harry Benjamin International Gender Dysphoria 
Association has formulated some elementary standards of care for transsexuals 
(16).  This work needs further elaboration before it can become a model.  
Researchers can begin to overcome the difficulty of small samples by combining 
data from several clinics.  This practice would obviously necessitate the use 
of standardized clinical instruments, clinicians with similar training back 
grounds, and uniform criteria for evaluation and treatment.  The crucial 
problem, however, is the availability of patients for follow-up.  
   Overview of Findings: Two Decades of Research 
   A review of the studies on sex reassignment surgery reveals a diversity of 
factors used to investigate postsurgical patients (appendix 1).  Results 
differ depending on which factors are focused on.  For example, those 
clinicians who used global ratings found a positive change rate of 68%-86% in 
the patients' overall social-emotional functioning.  On the other hand, those 
who used more discriminative evaluation criteria (focusing on psychological 
variables) not only failed to replicate these success rates but occasionally 
reported negative outcome in the socioeconomic area of postsurgical 
functioning.  All of these findings must be viewed in light of the various 
methodological weaknesses of the studies reported earlier. 
   Appendix 2 summarizes the positive and negative findings of the studies of 
sex reassignment surgery for over two decades of research.  Although several 
categories of change have remained constant, the more recent studies have 
focused on negative psychological functioning after surgery.  These findings 
may be directly related to the increased number of surgical procedures 
performed.  However, previous researchers had also sorely neglected the 
measurement of psychological functioning after surgery.  Perhaps the early 
postsurgery studies failed to report on psychological dysfunction because the 
evaluators, who were physicians and surgeons, lacked clinical psychiatric 
expertise.  Indeed, many of them believed that sex reassignment surgery would 
completely change the patient's personality structure for the better - thereby 
abrogating previous psychological disturbances.  While no single study has 
intensively evaluated the global psychological status of postsurgery patients, 
the recent focus on psychological variables and especially psychotherapy (54-
56) represents an important direction for research. 
   An analysis of those postsurgery studies which focused on the patient's 
psychological functioning revealed considerable discrepancy.  This was 
partially related to the definition of "psychological functioning."  The term 
(which has been used to describe anything from the frequency of psychiatric 
visits to responses to personality tests and data from psychotherapy) needs to 
be refined in terms of acceptable clinical criteria.  Moreover, the status of 
patients' self-reports about their subjective satisfaction or happiness with 
that procedure needs to be reconsidered as the sine qua non of outcome. 
   In a preliminary way the studies of the 1970s challenged the notion that 
sex reassignment surgery led to complete psychological integration of the 
patient's new gender role and identity.  While sex reassignment surgery may 
have provided the transsexual with artificial genitals, it did not provide the 
patient with the developmental history of a man or woman necessary for being a 
male or female, e.g., for the man, unique identifications with the mother, 
typical female preoedipal and oedipal development, experience of participation 
in a girls' social group, menses, and continued social-psychological reactions 
to female development.  While psychotherapy can be of considerable benefit for 
the gender dysphoric patient, it cannot provide the internal structures of 
maleness or femaleness necessary for internalizing cross-gender 
identification.  These identifications are primary structures established 
during early childhood and are not to be gained through sex reassignment 
surgery or psychotherapy.  One must not confuse cross-gender social role 
adaptation with one's internalization of gender identifications. 
   What, then, does happen after surgery with the gender dysphoric patient?  
In determining the success of sex reassignment surgery, should one use only 
the results of medical-surgical procedures (i.e., whether the new genitalia 
appear realistic and are functional)?  Or ought one to be concerned about the 
patient's psychological status?  While sex reassignment surgery is an invasive 
and irreversible procedure, presumed by some investigators to have a negative 
psychological effect on the patient, many questions are still unanswered by 
the research.  Do postsurgery patients exhibit more or less depression, 
anxiety, or guilt?  Are postsurgery patients more or less suicidal or 
psychotic?  What are the psychological sequelae of male castration and penile 
amputation and female mastectomies and hysterectomies?  While these clinical 
questions have not been fully answered by researchers, they certainly need to 
be addressed.  While most studies focus on variables that they have related to 
successful outcome, e.g., social, vocational, economic, and familial 
variables, future researchers need to refine their questions.  In spite of the 
apparent objectivity of these social variables, they are no less dependent on 
one's framework of values than more complex psychological variables.  For 
example, is a shy, with drawn, schizoid low-paid clerk who undergoes sex 
reassignment surgery and becomes an outgoing, highly successful female 
impersonator or prostitute (earning a high income and having a wide variety of 
social relationships) considered a success or failure?  What are the criteria 
used to determine outcome?  Bioethical dilemmas such as this need to be 
   The reported 68%-86% success rates for sex reassignment surgery must be 
viewed cautiously.  The lack of long-term follow-up studies makes these 
statistics misleading.  As long as sex reassignment surgery remains a viable 
treatment modality, it is reasonable to ask how one determines which patients 
will most benefit from sex reassignment surgery.  Currently the selection 
criteria available are informally culled from clinical guidelines established 
by the various gender identity clinics nationwide.  These criteria might be 
used in establishing universally acceptable guidelines for referring a patient 
for sex reassignment surgery.  In order for these guidelines to be effective 
one would have to ensure that sex reassignment surgery was done only by 
skilled surgeons in highly selected university-based clinics that could 
provide follow-up.  Essentially, this would mean limiting all sex reassignment 
surgery to a select number of hospitals in the United States.  While this 
raises certain ethical issues, it is clear that current abuse comes from the 
widespread availability of sex reassignment surgery and not the other way 
   While sex reassignment surgery has definite medical-surgical and 
psychological limitations, there is insufficient evidence to warrant its 
termination.  In deed, there is evidence suggesting that some gender dysphoric 
patients benefit primarily from sex reassignment surgery (reference 12 and an 
unpublished study by S. Satterfield).  The problem is how to identify these 
patients.  The growing body of literature implicating a neurohormonal 
hypothesis in gender dysphoria (57) also cannot be used to justify sex 
reassignment surgery, since the disorders of gender dysphoria are primarily 
psychological disorders, and it is rare to substantiate a neurohormonal 
disorder for any given case.  Most gender dysphoric patients, however, are 
secondary transsexuals (58) who can benefit from various modes of 
psychotherapy (54-56).  To date the evidence suggests that many patients who 
would have otherwise undergone sex reassignment surgery may adjust to a 
nonsurgical solution through psychotherapy (7).  Moreover, many misdiagnosed 
gender dysphoric patients need psychotherapy, not surgery (59).  Indeed, sex 
reassignment surgery should only be considered as the last resort for a highly 
select group of diagnosed gender dysphoric patients.  It is imperative that 
legislators who wish to provide Medicaid payments for transsexual surgery 
understand that, in most cases, alternatives to sex reassignment surgery are 
available to patients.  Physicians wishing to refer a patient for evaluation 
for sex reassignment surgery should be allowed to make use of the many 
specialized gender dysphoria clinics that are currently in operation. 
   As clinicians learn new ways to diagnose and treat transsexualism, either 
sex reassignment surgery will be abandoned as a routine treatment modality 
(reserved for only a few select patients) or new predictive variables for 
choosing suitable patients for sex reassignment surgery will be established.  
Future research needs to focus on long-term follow-up studies maximizing the 
use of those methodological issues outlined in this paper which will enhance 
our understanding of the etiology and the course of gender identity disorders.
  |Back to Sergical Menu | Back to Main Menu |
   1.      Benjamin H: The Transsexual Phenomenon. New York, Julian Press, 
   2.      Randell JB: Preoperative and postoperative status of male and 
female transsexuals, in Transsexualism and Sex Reassignment Surgery. Edited by 
Green R. Money J. Baltimore, Johns Hopkins University Press, 1969 
   3.      Walinder J, Thuwe I: A Social Psychiatric Follow-up Study of 24 Sex 
Reassigned Transsexuals. Copenhagen, Scandinavian University Books, 1974 
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WB Saunders Co, 1978 
   6.      Green R: Attitudes toward transsexualism and sex reassignment, in 
Transsexualism and Sex Reassignment Surgery. Edited by Green R, Money J. 
Baltimore, Johns Hopkins University Press, 1969 
   7.      Lothstein L: Psychotherapy with patients with gender dysphoric 
syndromes. Bull Menninger Clin 41:563-582, 1977 
   8.      Barlow D, Abel G, Blanchart E: Gender identity change in 
transsexuals. Arch Gen Psychiatry 36:1001-1007, 1979 
   9.      Lothstein L, Levine S: Expressive psychotherapy with gender 
dysphoric patients. Arch Gen Psychiatry 38:924-929, 1981 
   10.     Hertz J, Tillinger KG, Westman A: Transvestism: report on five 
hormonally and surgically treated cases. Acta Psychiatr Scand 37:283-294, 1961 
   11.     Meyer J, Reter C: Sex reassignment: follow-up. Arch Gen Psychiatry 
36:1010-1015, 1979 
   12.     Hunt DD, Hampson JL: Follow-up of 17 biologic male transsexuals 
after sex-reassignment surgery. Am J Psychiatry 137:432-438, 1980 
   13.     Jorgenson C A Personal Autobiography. New York, Paul E Ericson, 
   14.     Hamburger C: Desire for change of sex as shown by personal letters 
from 465 men and women. Acta Endocrinol (Copenh) 14:361-375, 1953 
   15.     Volkin V: Transsexualism: as examined from the viewpoint of 
internalized object relations, in On Sexuality: Psychoanalytic Observations. 
Edited by Karasu TB, Socarides C. New York, International Universities Press, 
   16.     Berger J, Green R, Laub D, et al: Standards of Care: The Hormonal 
and Surgical Sex Reassignment of Gender Dysphoric Persons. Galveston, 
University of Texas Medical Branch, Janus Information Center, 1977 
   17.     Prince V: Understanding Cross-Dressing. Los Angeles, Chevelier 
Publications, 1976 
   18.     Bullough VL: Transsexualism in history. Arch Sex Behav 4:561-571, 
   19.     DeSavitsch E: Homosexuality: Transvestism and Change of Sex. 
London, William Heinemann Medical Books, 1958 
   20.     Forgey D: The institution of bedarche among the North American 
Plains Indians. Journal of Sex Research 11:1-15,1975 
   21, Warnes H, Hill G: Gender identity and the wish to be a woman 
Psychosomatics 15:25-29, 1974 
   22.     Green R: Transsexualism: mythological, historical, and cross 
cultural aspects, in The Transsexual Phenomenon. Edited by Benjamin H. New 
York, Warner Books, 1977 
   23.     Money J, DePriest M: Three cases of genital self-surgery and their 
relationship to transsexualism. Journal of Sex Research 12:283-294, 1976 
   24.     Abraham F: Genitalumwandlung an zwei maenlichen transvestiten. 
Zeitschrift fur Sexualwissenschaft 18:223-226, 1931 
   25.     Hoyer N: Man into Woman. New York, EP Dutton & Co, 1933 
   26.     Money J, Brennan J: Sexual dimorphism in the psychology of female 
transsexuals. J Nerv Ment Dis 147:487-499, 1968 
   27.     Stoller R: Sex and Gender. New York, Science House, 1968 
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Dis 147:460-471, 1968 
   29.     Golosow N, Weitzman EL: Psychosexual and ego regression in the male 
transsexual. J Nerv Ment Dis 149:328-336, 1969 
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transsexuals. J Nerv Ment Dis 147:472 185, 1968 
   31.     Newman L, Stoller R: The oedipal situation in male transsexualism. 
Br J Med Psychol 44:295-303, 1971 
   32.     Kubie L, Mackie J: Critical issues raised by operations for gender 
transmutation. J Nerv Ment Dis 147:131143, 1968 
   33.     Money J, Ehrhardt A: Transsexuelle nach geschlechtswechsel. Beitr 
Sexualforsch 47:70-82, 1970 
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Acta Psychiatr Scand 47:106 133, 1971 
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Sex Behav 2:245-250, 1973 
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Menninger Clin 1:31-38, 1980 
   37.     Childs A: Acute symbiotic psychosis in a postoperative transsexual. 
Arch Sex Behav 6:37-44. 1977 
   38.     Van Putten, Fawzy I: Sex conversion surgery in a man with severe 
gender dysphoria. Arch Gen Psychiatry 33:751-753, 1976 
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Interdisciplinary Symposium on Gender Dysphoria Syndromes. Edited by Laub D, 
Gandy P. Stanford, University of California Press, 1973 
   40.     Gandy P: Follow-up on 74 gender dysphoria patients treated at 
Stanford. Ibid 
   41.     Ihlenfeld C: Outcome of hormonal-surgical intervention un the 
transsexual condition. Ibid 
   42.     Hastings DW, Blum JA: A transsexual research project at the 
University of Minnesota Medical School. Lancet 87:262-264, 1967 
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syndrome by surgical sex change. Plast Reconstr Surg 53:388-403, 1974 
   44.     Fisk N: Eight spectacular results, in Proceedings of the Second 
Interdisciplinary Symposium on Gender Dysphoria Syndromes. Edited by Laub D, 
Gandy P. Stanford, University of California Press, 1973 
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   46.     Gittleson N, Levine S: Subjective ideas of sexual change in male 
schizophrenics. Br J Psychiatry 112:779-782, 1966 
   47.     Gottleib A: Three atypical results. Arch Sex Behav 7:371-375, 1978 
   48.     Biber S: Surgical experience and follow-up of 100 transsexual 
cases, in Proceedings of the Fifth Interdisciplinary Symposium on Gender 
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School, 1977 
   49.     Hore B, Nicolle F, Calnan J: Male transsexualism in England: 
sixteen cases with surgical intervention. Arch Sex Behav 4:81-95, 1975 
   50.     Money J: Ablatio penis: normal male infant sex-reassigned as a 
girl. Arch Sex Behav 4:65-71,1975 
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187, 1976 
   52.     Sturup GK: Male transsexuals: a long-term follow-up after sex 
reassignment operations. Acta Psychiatr Scand 53:51-63, 1976 
   53.     Lothstein L: The postsurgical transsexual: empirical and 
theoretical considerations. Arch Sex Behav 9:547-564, 1980 
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surgery with psychotherapy. Am J Psychiatry 133:1194-1196, 1976 
   55.     Lothstein LM: Psychotherapy with patients with gender dysphoria 
syndromes. Bull Menninger Clin 41:S63 582, 1977 
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surgery. Arch Sex Behav 7:273-283,1978 
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up. Int J Psychoanal 60:433-441,1979 
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secondary transsexualism. Am J Psychother 28:174-193, 1974 
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reassignment. Am J Psychiatry 131:437-441 1974  
   APPENDIX 1.  Factors Investigated by Various Studies of the Results of Sex 
Reassignment Surgery 
   1.      Medical 
   2.      Surgical 
           a.      Patients' evaluation 
           b.      Physicians' independent assessment 
   3.      Psychological 
           a.      Psychometric scales 
           b.      Psychiatric interview 
           c.      Number of psychiatric contacts 
           d.      Number of psychiatric hospital admissions 
           e.      Suicide attempts 
           f.      Evidence of psychiatric symptoms 
   4.      Environmental 
           a.      Vocational and economic status 
           b.      Living conditions 
           c.      Income, amount and source 
           d.      Criminality 
   5.      Ability to pass in the new role successfully 
   6.      Use of drugs and alcohol 
   7.      Family and marriage 
           a.      Capacity for a lasting relation with partner 
           b.      Parental support 
   8.      Sexual adjustment 
   9.      Patients' subjective feelings about the surgical result 
   10.     Patients subjective feelings of happiness 
   11.     Overall assessment of result-global ratings 
           a.      Social rehabilitation 
           b.      Social-psychological 
           c.      Social-economic-psychological 
           d.      Social-biological 
   APPENDIX 2.  Summary of Positive and Negative Factors of Studies of the 
Results of Sex Reassignment Surgery Over Two Decades 
   Positive factors 
   1.      Acceptability as a man or woman 
   2.      Subjective satisfaction with surgery 
   3.      Social Adaptation 
           a.      Lessened conflict with the environment 
           b.      Improved family relations 
           c.      Increased capacity to work, new and better job status 
   3.      Social adaptation 
   4.      Physicians' assessment of surgical results 
   5.      Psychological changes 
           a.      Decreased levels of anxiety 
           b.      Decreased level of depression 
   Negative factors 
   1.      No maternal response 
   2.      Failure to develop an inner schema of femaleness 
   3.      Suicidal threats, gestures, and behaviors 
   4.      Psychiatric disturbances, including drug addiction and depression 
   5.      Role re-reversal, requests for re-reassignment 
   6.      Homosexual prostitution 
   Positive factors 
   1.      Subjective satisfaction with sex reassignment surgery 
   2.      Increased sexual satisfaction 
   3.      Remission of certain forms of schizophrenia 
   4.      Increased vocational-economic adjustment 
   5.      Improved psychological status correlated with good surgical results 
   6.      Patient's subjective feelings of happiness 
   7.      Lessened conflict with the environment 
   8.      Decrease in acute symptoms 
   Negative factors 
   1.      Requests for more surgery 
   2.      Increased psychiatric illness (73% in one study) 
   3.      No change in psychological status 
   4.      Poor cosmetic appearance 
   5.      Requests for reversal of surgery 
   6.      Massive lawsuits 
   7.      Medical problems (e.g., one patient left decorticate, another 
having a leucotomy) 
   8.      Patient left in "freak status," cannot pass in new role or adopts a 
lesbian status after male-to-female sex reassignment surgery 
   9.      Suicidal threats, gestures, and behaviors 

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