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Friedemann Pfäfflin, Astrid Junge
Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991(Translated from German into American English by Roberta B. Jacobson and Alf B. Meier)

Follow-up Studies
Table of Overview
Results and Discussion

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book Historic Papers
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Quick Orientation
The volume reviews thirty years of international follow-up studies of approximately two thousand persons who have undergone sex reassignment surgery.

Usually, surgery was performed due to a condition which, in medical terms, is called transsexualism. The volume includes more than seventy individual studies and eigth previously published reviews from many countries and four continents. It describes the history of sex reassignment, the development of the various treatments applied, the procedures of documentation and evaluation, and the results.

The individual studies and reviews are annotated by the authors, and are discussed within the frame of the development of the field. Sex reassignment, properly indicated and performed, has proven to be a valuable tool in the treatment of individuals with transgenderism.

It is, however, not the only powerful change agent in sex reassignment. Real Life experience, hormone treatment, counseling, psychotherapy, legal name and sex change, and other factors play major roles in contributing toward favorable outcomes.

The quick reader finds an overview of all studies included in the chapter "Table of Overview" and a summary of all results in the chapter "Results and Discussion". This reader is encouraged, however, to start with the paragraphs on terminology in the chapter "Introduction" to become acquainted with the abbreviations "FMT" and "MFT" and the usage of the words "male" and "female" in the book.

The authors wish to express their appreciation to Symposion Publishers for their support and for offering the book as a supplementary volume of The International Journal of Transgenderism (IJT). The International Journal of Transgenderism will include full-text versions of the most important original follow-up studies and reviews discussed in the book in its section "Historic Papers" in forthcoming issues. Readers of The International Journal of Transgenderism will thus have direct access to these papers by links and will be able to review the evaluations of the authors.

Since publication of the German version of this book by Schattauer-Verlag, Stuttgart and New York, in 1992, a number of further follow-up studies have been published which confirm our conclusions.

Still needed are more follow-up studies of attempts to create male genitalia. Techniques are constantly improving in this field, perhaps not as rapidly as one might wish. Instead of studies from individual centers only, multi-site studies would be much preferable. The International Journal of Transgenderism will put all its endeavor into presenting progress in this field.

This contribution provides an overview of follow-ups of patients with transsexual symptoms who have undergone surgical procedures to adjust their physical appearances to images these men or women had of themselves.

There are three main reasons that prompted us to present this. The first is the major need for information about the various groups as well as our immediate clinical activities. Primarily, the patients want to know what the results of the treatments are. They want to know it for themselves and want to be able to give their family members information. However, the referring general practitioners, specialists and psychologists need -- in order to counsel adequately -- information that is as broad as possible. Finally, the medical insurances and other liable parties, as well as courts that in cases of dispute have to decide liability, need to be able to access reliable data.

The second reason is that in the maintained discussion about whether or not these procedures are justifiable, the claim that there are not sufficient post-surgical examinations is repeated almost ritually. Not seldom this claim is also made in scientific literature (e.g., Docter, 1988); this mainly has the function either to evade the efforts that it signifies to collect widely spread literature and to evaluate it, or to suggest that one's work is a new area. There is, as we will show in the following, ample international literature about follow-ups, more vast than with other illnesses and many other routinely used treatment methods. The literature is frequently not very accessible because it was published in reviews and books not available in most medical or university libraries. Not everybody who has worked on this topic has had the time to order (by way of distance lending) and review all this literature. What has been missing until now is a sufficiently vast overview of the topic. The latest overview (Green & Fleming, 1990) regards only 11 single works and three previously published (incomplete) reviews.

The third reason is that we deem it necessary to include content or methodical remarks and, in addition, state out of which contexts follow-up studies originated and what goals the respective authors were pursuing. The attitudes of the authors have been made evident independently if they refer to them directly or if they write about them in the sense of speech, "between the lines." The attitudes are evident in the selection of words and statements about the patients in which the authors and caregivers express their big ambivalence about what they are doing, mostly without really reflecting on it. Frequently this leads to characterizations of patients that they (the patients) must experience as demeaning or else make them appear in an unpleasant light. It is best to illustrate what we mean with a few examples. If a work has the title Course of Treatments and Katamnesis of Operated Female Transsexuals (Junge, 1987) and describes previous patients who now live as males and have legally completed a name change and legal sex change, then this title reflects less that what the previous patients actually have achieved. Most of them do not view themselves as transsexuals -- and definitely not as female transsexuals -- but as males. To us it seems just as problematic if an author who provided psychiatric care to patients for years referred them for operations and then post-examined them, declares that the desires of the patients to be recognized legally as a member of the other sex is "...an untenable request in my view, for I do not subscribe to the opinion that a phenotypic male can have a female psyche. Those who profess to have such mental orientations are in fact anatomical males with obsessional beliefs or over-valued ideas that they are females; and therefore psychiatrically abnormal." (Randell, 1969, p. 367) "Only a minority accept it for what it really is - that is, a neutering procedure or, perhaps more correctly, a castrating process. It is difficult to persuade transsexuals who have had their genitals removed that they are, in fact, nothing more than castrated males...Following operation, there was a tendency to further self-deception over sexual status, and at least nineteen regarded themselves as having achieved the female sexual status." (Randell, 1969, p p. 375-376)

  Because of the reasons mentioned, we will first give a complete as possible summary of the follow-ups published until now. Because of the vast number of publications on the topic of transsexuality, we shall limit the selection to such works in which the treatment results of at least five operated patients are documented. We do not include single case reports or katamnesis of smaller samples because we do not consider them post-surgical examinations in the proper sense. In some cases they are more informative than the descriptions of larger samples, but because they are geared toward description of the particulars of individual development, they are not suited to be used comparatively and to reach generally applicable conclusions. We realize that completeness can only be reached approximately. This is why we ask of authors whose works we missed for forbearance and ask them for leads to their works. We must also mention our limit, that we could only view English and German-language professional literature and cannot judge if follow-up studies have been published in other languages, or how many. Disregarding this limitation, we arrived at 70 follow-up studies and eight reviews from the years 1961 - 1991, far more than have ever been examined in other single works or collective reviews. Of particular note, we have compiled a series of German-language post-surgical examinations not mentioned in the almost exclusively English-language overview works, probably because the publications in which they were published are not included in American Index Data Bases.

Because as we refer to every single work or collective paper in chronological order, we give an overview in the genealogy of the study of post-surgical examinations to transsexuality. We deem it important to examine the critique that is sometimes made (Springer, 1981) that transsexuality as an illness whose treatment is an invention of a small circle of so-called sex researchers who constantly quote one another. This criticism was repeated without proof by the medical insurances or expert witnesses for the insurances in social court cases during the 1970s and 80s in Germany, by which the medical insurances have tried -- without success -- to avoid liability for the costs of treatment.

The inclusion of every individual work is not solely for the purpose of compiling the main treatment data of the described patients, but also to illuminate the peculiarities, position and opinion of the examiner. If one would, as it is usual in collected works, just present the results of post-surgical examinations as tables, we could have saved much space. We would, however, either have a false impression of objectivity or could retire, as it frequently happens, to a generalized methodology critique. Many follow-up studies are hardly comparable to each other, even though their results condensed into extracts may appear quite similar. Most authors have worked hard and should therefore be heard. The reader is invited to fathom, by means of the ample material about follow-up studies, the development, stagnation, evolution of new questions.

In the terminology, we diverge from other follow-up studies and reviews fundamentally in that we avoid the standard terminology "he" and "she" regarding transsexuals wherever possible. We think that the frequently used clinical abbreviations the Transi, the Transe, the Transen are even more unpleasant. It all reminds us too much of expressions such as "the appendix in room six," "the apoplexy," "the alcoholic," "the gall." Also the words "biological male or female" or "male-to-female" or "female-to-male transsexuals" that we used in previous publications are considered unsatisfactory by us. In the American-English language, these terms are common. German authors who are not familiar with the professional discussions but like to publish in English even use "man-to-woman" and "woman-to-man transsexuals." (Täschner & Wiesbeck, 1988a) We prefer to talk about people, persons or patients with transsexual symptoms. It is true that transsexuality is about (gender) identity, so that substantiveness is more called for than in other cases and that some patients identify themselves with these terms, but they consider them titles of honor which they do not wish to renounce. Others deny such terms from the beginning and declare that they always view themselves as male or female. On the other hand, other patients may accept them -- as long as they are not operated -- but insist after the operation they are not transsexuals. We will not be able to satisfy everybody, no matter what the wording. As important as the transsexual topic is to the individual, we are opposed to reducing anybody to it. After completed surgical treatment, we speak only of "females" and "males" oriented on which gender the subject considers one's self. Because most of them have completed a name change and legal sex change, this mostly corresponds to one's experience and also to the legal position as a female or male.

Naturally, this evaluation elected by us is not without problems because it makes the surgical procedure the turning point that does not represent the individual transsexual development. Under the aspect of treatment we highlight, to the contrary, the mostly relative significance of the surgical procedure for the managing as male or female. Here we do not discuss the treatment instructions, but rather treatment results. While before surgery, and as such without surgery, a legal sex change is possible in Sweden, this is not true for all other countries. The legal change of the gender is conditioned to a sex reasignment surgery. Most follow-up studies do not mention this legal step, which does not correspond immediately but is part of this treatment. The exact time at which a patient is defined as male or female is not important to us, but rather the time at which the new status is accepted and that one is not stuck with a particular diagnosis until the end of one's days that may have been important in a certain segment in life, but does not define one's whole life.

For the following representation, the problem is complicated by a population of patients where samples and partial samples have to be compared constantly with one another, in which males and females have to be described before, during and after treatment. We can hardly do without abbreviations, especially in the tables, if the overview is not to be totally lost. To solve this problem, we have elected abbreviations or codifications that we not only used in the tables but in the text and we did not write out fully on purpose. For patient population which includes operated and non-operated without distinguishing by gender, we use the code T. For samples in which there are males who have been operated on and those who have not been operated on, we use the code females (MFT). For samples of females who have been operated on and females who have not been operated on, we use the code males (FMT). The corresponding figures for mixed population of that kind -- unless there are other corresponding indications in the original text -- are put in parentheses. For males who are still in treatment and have not been operated on, we use the code MFT. For females who are still in treatment and have not been operated on, we use the code FMT. In the rare cases in which a patient has been operated on and the code T should be deleted, it is kept if the patient returns to the original gender role in spite of the operation. Simplified, we can summarize that until the operation, and in case of a so-called role-return, the code T is valid; after the operation females or males are described by their present classification. We want to make clear that these classifications are to be understood as codes and not as descriptive categories. This sounds much more complicated than it is in reality and readers will easily find their way through the text; as females (MFT) in principle are compiled in the left column and males (FMT) in principle are compiled in the right column; with all post-surgical results, the new classifications as female or male is applied.

Terminological problems are caused by the term used in the examinations of the operation results. In letters from doctors and expert attests -- including our own, but also in literature -- you find expressions such as "plastic surgical construction of the neo-vagina," resp., "neo-phallus," "mammary reduction" or "augmentation." The neo-vagina is also called vaginoid or artificial vagina; the neo-phallus, artificial penis, substitute penis or penoid and if it is a clitoral augmentation, it's called clitoris-penoid. As a rule, this all sounds much more artificial than it looks and, more importantly, as it is experienced by the patient. This is why we use the simple terms "vagina" or "vaginoplasty," "penis" or "phalloplasty," "clitoris augmentation" and "surgical breast augmentation" or "reduction." The other medical terms such as hysterectomy, ovarectomy, mastectomy, penectomy and orchidectomy, we were not in the same way consequent because the medical terms -- especially within the small space of a tabular representation -- were allocated easier.

We use the terms "transsexualism," "transsexuality" or "transsexual" as sparingly as possible and rather talk about, as explained above, transsexual development, transsexual symptoms, etc. In some older follow-ups, the terms transvestitism and transvestites are still used. Until the mid-1960s it was not usual to talk in German literature about transsexualism. The corresponding phenomena were summarized under the term transvestitism, termed by Hirschfeld (1910), to separate and define properties of certain clinical developments summarized until the end of the last century under the term homosexuality. Hirschfeld (1923) first mentioned "psychic transsexualism" in passing, but it was not accepted. Even though transsexualism literature mentions it until today, with the exception of Seidel (1969), Eicher (1984) and recently Sigusch (1991a, b), it is not true that the originator of this term is Cauldwell (1949), but Hirschfeld (1923). With the works of Benjamin (1953; 1964 a, b, c; 1966; 1967; 1969) as well as the popularization of the clinical history of the former American soldier Christine Jorgensen (Hamburger, et al., 1953; Jorgensen, 1967), the term transsexualism was established in everyday language as well as in professional literature. At the same time there was a separation from the transvestitism or so-called compulsive cross-dressing mania. What is called temporary in transvestitism -- the playful or compulsive changing into the other sex role -- is a permanent characteristic of transsexualism. The classic description in the medical literature and the key diagnosis is that, to the contrary of physical appearances, individuals experience themselves as belonging to the "other" gender and do everything so that their experiences take form and are acknowledged by others.

Finally a word from us for the term used in the title and continuously used throughout this text - "sex change." It is controversial when we are referring to the evaluation of the treatment whose results are broadly represented here. Persons who experience themselves as transsexuals will, as a rule, try to get hormonal, surgical and legal sex changes. Some say simply that they don't have to be changed, but only adapted physically to their own gender. In American-English, the short definition "sex reassignment surgery" (SRS) has been established by which the assignment process is best defined. At the beginning the term "Geschlechtsumwandlung" (sex change) was transposed from German to American English. Benjamin (1966), who was from Berlin and later moved to the United States of America, prepared the way for sex reassignment treatment (Pfäfflin, 1997) and defined in his publications the processes as "sex change operation, conversion operation, change of sex, conversion, transformation." All these terms are used by other authors, but the one used mostly, as said above, is "sex reassignment surgery." It should be noted that occasionally the terms "gender transmutation" (Kubie & Mackie, 1968; comp. Lothstein, 1980) and "gender reassignment" (Mate-Kole, et al., 1990) are used -- even though in the professional discussion about transsexualism it is always specifically mentioned that in American-English (to the contrary of German, which only has just one word for "gender") there is a distinct difference between sex and gender (Stoller, 1968, 1975) -- and that surgical sex change is the equalization of the corporal sexual characteristics (sex) to the sexual identity (gender).

Many authors have raised objections to the use of the term sex change. Randell (1969) already mentioned concerns about it. Eicher, who presented the first German-language monography about transsexualism, considers this term as "incorrect, because only an equalization to the psychological gender is realized. The possibility of a gender-specific reproduction can never be achieved " (Eicher, 1984, p. 1; italics F.P. and A.J.). More important, it seems to us, are the objections raised by Hertoft and Sörensen (1979), who stress that the term suggests that a sex change is possible, in reality being impossible. Further, that it contains a seductive promise that cannot be fulfilled. They regard surgical procedures as a desperate attempt to solve a deep conflict in which the solution is frequently poor or is no solution at all. According to their opinion, one should not suppose that through such a surgical procedure a human being can be changed. The number of those for whom an operation has been recommended as an emergency measure and who have profited by it is small and all others know deep in their psyche that they have not changed their gender.

This critique for the use of the term sex change in connection to sex reassignment surgery stems from the concern about the patient, to take the patient seriously. The term change raises hopes, possibly nourishes illusions and reminds one of the magic word "mutabor" in the tale 1001 Arabian Nights. We have chosen it despite all of this and justify our decision by the same argument - out of concern for the patient. If psychology, medicine and the law agree to the desires of patients, regardless of their reservations, and support the patients to live in accordance to their self-image as a member of the opposite sex, then they contribute -- however limited -- to a changing process that results in a human being who was born as a boy or a girl to live as an adult as a female or a male. As a rule, this is a difficult process full of conflicts that burden the patient enough. It is our task to make this destiny as bearable as possible. The surgical operations are -- if done appropriately -- just a few of many steps in a changing process requiring and containing many interior or exterior changes. The patients will adapt to the results of the treatment better the more their intents to face this conflict find support. Under retrospective biographical aspects, it may be true that a human does not fundamentally change - regardless of any operations. Even though a new human being has not been created, there has been change, along with many new experiences. To treat patients first psychiatrically, hormonally and then surgically and then to inform them, as Randell did, that they are only castrated males and females, is considered by us inappropriate and hardly conducive. Due to psychological reasons and because a legal sex change is a real change, we consider it legitimate and proper to talk about gender change and/ or sex change.