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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 post op teen transsexuals those who have been studied represent an adequate cross-section of all sex reassignment surgery post op teen transsexuals patients. If not, this sampling bias is a primary methodological problem inherent in all post op teen transsexuals 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
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