In 1974 Pauly published two articles on female transsexualism which have served as the major resource for researchers and clinicians. In those articles he reviewed the world literature on female transsexuals which consisted of descriptions of eighty cases. The cases were all reanalysed post hoc using a 102 item instrument (which was not presented). Additionally, he provided a substantial bibliography for future researchers.

Citing prevalence studies of female transsexuals in Sweden and the USA, Pauly reported that for women over 15 years of age the incidence of the disorder was 1/103,000 and 1/130,000 respectively, while ratios of male to female transsexualism were 3:1 and 1:1. Pauly noted that during the 1960s there was an increasing number of females requesting SRS.

Pauly's analysis suggested that female transsexuals perceived their mothers as needing protection from their fathers. Indeed, the transsexuals' mothers were viewed as cold, rejecting, emotionally disturbed, and unavailable. The patients were also seen as masculine, identifying with their fathers (who were viewed as large, masculine, alcoholic, physically abusive, and assaultive men). A large number of the women were raised in rural settings, and with the exception of one Mexican American, all were Caucasian.

The women reportedly first became aware of their cross gender wishes around age 7 (range 2 13 years). They were disgusted by their breasts and female genitalia and envied boys their genitals. Many of the women prided themselves on being the toughest kid. Puberty was traumatic, with the onset of menarche and the development of breasts shattering their hopes of ever being male. All of the women denied being homosexual and chose feminine women as their lovers.

Pauly concluded that "the breasts are the most obvious insignia of femaleness and the first point of surgical attack." His views have been substantiated by other investigators who concurred that the majority of female transsexuals who had a mastectomy did not go on to have phalloplasty; it was primarily their breasts which they wanted removed.

In his second study, Pauly (1974b) focused on the psychological and psychiatric status of these same patients. However, since the analysis was post hoc it must be regarded with a certain amount of scepticism. Pauly reported that on various IQ measures the female transsexuals scored above average (the mean IQ scores of 105 are highly unreliable since no standard test was administered). The majority of patients came from lower socioeconomic classes and had at least a high school education. Only one of the thirty five patients was thought to be schizophrenic; six patients (24 per cent) were seen as delusional (with the delusions focusing on their belief that they were of the opposite sex). Pauly distinguished between ideas of sexual metamorphosis, confused psychosexual identification, and gender confusion as related to diverse psychiatric conditions such as psychotic states, schizophrenia or transsexualism. He concluded that female transsexuals are neither psychotic nor delusional "and certainly not schizophrenic in the majority of cases reported." He also reported that "on most of the psychological measures, female transsexuals seem to be better adjusted, freer of paranoid trends, and more realistic in their appraisal of what is possible for them [than male transsexuals]." He did, however, report that 34 per cent of them had personality disorders, and that depression was a primary problem (with 17 per cent making suicide attempts). Pauly cited Baker and Green's (1970) study in which a female transsexual reportedly committed suicide ten years post surgery. A review of the literature revealed only one other case in which a woman attempted to mutilate her breasts or genitals, a phenomenon which was quite rare among female transsexuals. (see FEMALE TRANSSEXUALISM PART VI)