References to the Treatment

• Psychiatric-psychotherapeutic treatment
• Hormonal Treatment
• Surgical Treatment
• Legal Sex Change

Psychiatric-psychotherapeutic treatment
Disregarding few exceptions, the references to psychiatric and/or psychotherapeutic treatments are short or lacking. If such treatments are mentioned, which is not the case in all follow-up studies, then they are described very superficially. This stands in contrast to the explicit demand in some works for psychiatric pre-, during and post-treatment. One can find explicit references, for example, in Wålinder (1976); Wålinder & Thuwe (1975); Vogt (1968); Alanko & Achté (1971); Sörensen (1981 a, b); Lothstein (1982); Eicher (1984); Dudle (1989); Pfäfflin & Junge (1990); Eicher et al. (1991). Two works are, due to their emphasis, psychotherapy reports rather than follow-up studies (Lothstein, 1980; McCauley & Ehrhardt, 1984). They are the only ones who report more in-depth about psychotherapeutic themes. Apart from this there are some works that refer to the importance of the social work and legal work (for example, name change) (Walser, 1968; Randell, 1969; Hoenig, 1970 a, b) or they recommend a broad life guidance program including body-building; cosmetic advice; cross-training with the labor office; recommendations regarding insurance, retirement and specifics on renting and even the long-term living with a patient who has had surgery already (Laub & Fisk, 1974). The specifics of psychiatric treatment, its possibilities and limits, are not really given.

Even in those works that stem from psychiatrists, one misses -- until the late 1970s -- almost everywhere detailed references about how long, with what frequency and content and with what method and results treatment was made. Instead one finds statistical descriptions, a chaining of psychopathological potraits,description of psychopathological conditions, but no mention of developments caused by psychiatric and/or psychotherapeutic or other treatment components.

There are different aspects that can help to explain this remarkable circumstance. The first is the taking over without critique of the thesis of Hertz, et al. (1961) that psychiatric treatment has been proven as ineffective regarding the phenomena of transsexualism, that has been approvingly cited by many other authors. In four of five case studies in the publications of Hertz et al. (1961), it is cited explicitly that psychiatric treatment is to be regarded as useless. Based on this premises, there seems to be no necessity to describe psychiatric treatment intents or even to mention them. Hormonal and surgical treatments on the one side, and psychiatric treatment on the other side, were seen as alternatives. Vogt (1968) said in this sense specifically that the hormonal treatment was started if more than one psychiatric treatment had failed and his impression was that the psychiatric treatment possibilities had all been tried. His practical method negated this: He only took patients into hormonal treatment if they were ready to be treated by him also psychiatrically. We suppose that the follow-up studies do not transmit a complete picture about the previous psychiatric treatment. To the contrary, many things lead one to believe that the earlier publications, including those of Hertz et al., described patients who had been treated, to different extents, by psychiatric methods. Hoenig et al. (1971) even reported about a surgical procedure in the brain, such as was recommended earlier by Randell (1959): On a patient who was deemed, for undescribed reasons, unsuitable for sex reassignment surgery, a lobotomy was performed. Because the psychiatric treatment generally, not only the leukotomy, that was also classified afterwards as inadequate by Hoenig et al. (1971), was ineffective in regard to the symptoms and it was considered by psychiatrists as worthless.

It is to be supposed that, under these circumstances, psychiatrists and patients, if there was psychiatric treatment, frequently talked at cross purposes. The patients noted that the "severe treatment program," of which, for example, Spengler (1989) talked, was, just like he himself said, a "waiting period". Some follow-up reports allowed patients to evaluate retrospectively the help they had received by this psychiatric treatment. The corresponding judgment was not very good (for example, Sörensen, 1981 b; Junge, 1987).

Stone (1977) has neglected the description of psychiatric treatment elements for totally different reasons than the authors mentioned thus far. Very colloquial he declared that if a patient needs a psychiatrist, then that alone is already a contra-indication to surgical treatment. But this is evidently the opinion of an outsider.

There is another point of view that could explain why the psychiatric-psychotherapeutic treatment is referred to so marginally in follow-up studies. Corresponding to their apologetic premise, the attention of the scientists was concentrated in the first two decades of follow-up studies of larger groups to demonstrate the effectiveness of the disputed surgical treatment. The "cause(s)" of transsexualism was not known, but the adepts of somatic cause hypothesis were, in agreement with the adepts of the Stoller claim of a Core Gender Identity that a predisposition, early-forming fixation or however they understood the disposition to transsexualism that could not be influenced by psychotherapy. At the most, they wanted to filter so-called untrue or secondary transsexuals, in whom the identification to the opposite gender was not considered as fixated as in the so-called true or primary transsexuals. The interest of research was toward development of gender identity (e.g., Money & Brennan, 1968; Money & Primrose, 1968). In this background, patients were -- in some institutions -- primarily research objects, not persons who needed psychiatric and/or psychotherapeutic treatment. So it could be tested in a design that seemed experimental, whether or not so-called sociopaths could be changed structurally by surgical procedures (Hastings, 1974). The primary part of the treatment was "the surgical procedure" and as Meyer and Reter (1979) formulated it, most markedly "the passage of time in association with some contact and acceptance into an organized evaluation program" (p. 1014). "The program is interested, concerned, but not interventive, recognizing the strenght of the wish for sex reasignment , but adopting a position of watchful waiting" (p. 1015). This expression shows that the researchers saw themselves more as realizers of a program, less as subjects who also see subjects in the patients. It is not surprising that these authors who have, like only a few others, explored psychodynamically relevant materials, namely, fantasies and dreams, do not report anything about this in their follow-up study.

The acknowledgement that psychiatric accompaniment and/or psychotherapeutic conflict resolution is useful or helpful -- independent if the desire for sex reassignment surgery was abandoned or not -- progresses only slowly, as can be seen exemplary in the writings of Pauly. In his first overview work (Pauly, 1964), he contrasted the poor success chances of psychotherapeutic treatment with the faster, cheaper and with better chances for success of surgical treatment. In the following overview (Pauly, 1968) he declared that the role change may, depending on individual circumstances, occur before or after the surgery, thus neither requiring a Real-Life-Test, not to mention psychiatric or psychotherapeutic treatment. To the contrary, he declared categorically that psychotherapy has failed in the intent to reconcile patients with transsexual symptoms with their physical endowments. There is no alternative to surgical treatment. Psychotherapy is only useful then if it is intended for helping the patient with adapting to the new gender role. As three important factors for a good result, he named, "functional use of an artificial vagina, ...legal change of gender status and freely pass(ing) in society as a member of the opposite sex" (Pauly, 1968, p. 460). Later he remarked that "transexualism would be far better prevented than treated "(Pauly, 1974b, p.509) and it seemed important for him to add that in 96% of the sample described by him initially and before any therapeutic measures (the patient) had been evaluated extensively psychiatrically and that the psychiatrist recommended in 93% of the cases hormonal and surgical treatment. (Pauly, 1974 b, p. 515). Only in reaction to the works of Meyer & Reter (1979), various reports about psychotherapy that had caused a lessening or a disappearance of the symptoms (Barlow et al., 1973, 1979; Davenport & Harrison, 1977; Dellaert & Kunke, 1969; Kirkpatrick & Friedman, 1976) and the work of Lothstein & Levine (1988) he revised his former opinion and wrote, "Rather than argue about whether any of these gender dysphoric patients treated successfully with psychotherapy were indeed true transsexuals, I feel it best to acknowledge that one should explore all possible alternatives in the management of these challenging patients before recommending sex reassignment surgery" (Pauly, 1981, p. 50).

It was already Wålinder (1976) who remarked about the importance of supporting psychotherapy. Alanko & Achté (1971) called hormonal and surgical treatment mosaic pieces and declared categorically that therapeutic success cannot be achieved with surgical treatment alone. They demanded pre-operative psychiatric treatment of at least two years and -- if possible -- additional psychotherapy that should be at least as long. For the post-surgery time, they had recommended a many-year-long supportive psychotherapy.

The psychotherapeutic and psychiatric aspects of treatment before and after surgery have been considered more important since the 1980s. (Lothstein, 1980; McCauley & Ehrhardt, 1984). The treatment guidelines of the Harry Benjamin International Gender Disphoria Association, Inc. -- that were introduced in 1979 and have been revised repeatedly since -- already mention this aspect, but did not give it greater importance because in the title only hormonal and surgical treatment were mentioned (Walker et al., 1985). It was only in the 1980s that the study of single components of the treatment in relation to their effectiveness was started (e.g., Blanchard et al., 1985; Kuiper, 1985; Fahrner et al., 1987; Kuiper & Cohen-Kettenis, 1988), which we will discuss later.

It seems that most authors have little interest in it, or do not feel competent in endocrinological aspects. This is presumed because of the extreme differences regarding the selection and dosage of hormones found by Meyer et al. (1981) in comparing the treatment schemes in 20 different centers. In 20 centers there were eleven different regimes for giving testosterone to FMT and at least nine different hormonal schematics for MFT. Insofar as patients have not been treated in gender identity clinics, it has to be counted on additionally that hormonal treatment and different treatment elements were in different hands and that complete documentation about hormonal intake was not readily available. Finally, it has to be considered under this aspect that many patients take different hormones uncontrolled and that they can't give or don't want to give the researcher complete information.

There are certain follow-up studies that give exact data about the dosage and the length of intake of hormones (e.g., Vogt, 1968; Wyler, 1978; Dudle, 1989) but these samples are small and the specific effects of the hormonal treatment were not specifically analyzed. In some older cases they first tried "same sex" hormonal treatment, hoping that the transsexual symptoms could be put back by it and only after the failure of such intents was an "opposite sex" hormonal treatment started (e.g., Vogt, 1968; Stürup, 1976). The times elected for the start of hormonal treatment were unequal. Mostly hormones were given first and after that, patients underwent surgery. But there are -- primarily in early samples -- single cases in which surgical treatment was done first (e.g., Alanko and Achté, 1971).

It is remarkable that, according to many U.S. publications, hormones were given from the beginning - seemingly from the first or second contact. The requirements of the adaptation to the opposite gender role in daily living were not fulfilled by many patients, either in the aspect of an indication for hormonal treatment or indication for surgical treatment - and probably not even required by the treating physicians. Benjamin (1967, p. 117), for example, recommends "several months of observation are advisable, preferably under estrogen treatment," so that the time point stays open from which the hormones are considered to be indicated. In not just a few studies, one gets the impression that the treatment provider and the follow-up researcher did not take their own indication criteria very seriously. It seems to us to be particularly careless how hormonal treatments were undertaken (and the indication for breast augmentation for MFT) as described by Edgerton & Meyer (1973) as well as Turner et al. (1978).

Overviews about control studies of hormone intake and effects can be found -- apart from the specific follow-up studies -- in Meyer at at. (1986); Asscheman (1989); Asscheman et al. (1988 a, b); and Lips et al. (1989).

Surgical Treatment
Even if not exclusively, the follow-up study literature treats the effectiveness of "the surgery(ies)". Given this background, it is astounding that only in about half the publications is it specified what surgical treatments were done and even more seldom to which results they led. In other works, it is evidently presupposed that the reader knows what is meant by "the surgeries", which in one case, was even brain surgery (Hoenig et al., 1971). In-depth representation of surgical techniques in the genital area are found in Edgerton & Meyer (1973); Turner et al. (1978); Zingg et al. (1980) and Eicher (1983, 1984).

The condition to extend the indication to "operate" were not uniform in different treatment centers and, above this, have changed during the time period of this report, but the changing process can be seen less in literature about follow-up studies than in general works about transsexualism (e.g., Hertoft & Sörensen, 1979; Springer, 1971; Langer, 1985). The selection criteria contained in some publications were not seldom disregarded by caregivers themselves (e.g., Stone, 1977; König et al., 1978) and the indication recommendations given at the end of many publications do not stem from research of follow-up study results, but rather have been copied without having checking in the general literature about transsexualism for other follow-up studies (e.g., Wiesbeck & Täschner, 1989).

Some early operations were legitimized with the argument that castration surgery would achieve a lessening of sexual urge, and a calming that could be, for people who suffered about their gender and sexuality, a lessening of their burden. Hertoft & Sörensen, 1979, who analyzed the background of surgical indication of Christine Jorgensen in detail, and interviewed the psychiatrist Georg Stürup, who participated in the treatment indication, wrote "It is clear that Chris Jorgensen, who had Danish ancestors, wanted to change sex, but the medical team did not originally intent to perform a sex-change operation; it only moved in that direction... the Danish team regarded Chris Jorgensen as a homosexual man suffering from his homosexuality and since he himself asked for castration, they would not deny him this operation. Not until afterwards, when the press published the case, did the team behind the procedure accept it as a sex change" (Hertoft & Sörensen, 1979, p. 168).

The follow-up literature does not analyze these backgrounds more specifically, but one can demonstrate by it that "surgical procedure" not always is understood as the same. Many of the earlier operations on MFT were only castrations or penectomies. Except in the samples of Benjamin (1964 a, b, c; 1966; 1967) in which most patients who underwent this surgery also received vaginal surgery, one can find in all other samples of the 1960s marked differences between the frequency of the different surgical steps. In Hertz et al.

(1961) and Gunn-Sechehaye( 1964) only about half of those operated had vaginal surgery; in Randell (1969) it was only about one-third (11 of 29) and in Walser (1968), who reports about earlier courses, it was only one of six penectomized, resp., seven orchidectomized patients who also received a vaginal operation. In later follow-ups, comparable discrepancies exist only in Spengler (1980), which is dependent upon his short follow-up study time (in six of 13 patients the then-normal two-part surgery was not finished), as well as Lindemalm et al. (1968) in which only nine of the 13 of the operated patients also had vaginal surgery. For fear of judicial consequences, sometimes the testicles were not removed, but only transplanted, that is, retro- or supra-peritoneal transposed under the stomach skin (Benjamin, 1964 a; Randell, 1969; Alanko & Achté, 1971; Hoenig et al., 1971). By the way, as was explained more in detail in the section Follow-up Study Periods, until the beginning of the 1980s sex reassignment surgery was divided into several surgical steps that could be months to years apart.

The surgical techniques were (and still are today) different, depending on the opinion, experience and technical ability of the surgeon and on the individual characteristics of the patient. To structure the vagina, stuffed in penile or scrotal tissues were used, or free skin transplants from other external bodily regions or from the colon. The erectile tissue was removed completely or partially to fill up the (vaginal) lips with the rest. The penile glans was removed or it was used to imitate a cervix and placed into the depth of the vagina, or parts of it were used to form a clitoris. In not a single follow-up study was the employed technique ordered in a useful, statistical manner to the treated patients and the treatment results.

This is also valid for additional surgery, such as breast augmentation, as well as face-lift surgery, rhinoplasty, thyroid surgery or vocal chords, etc. (comp. Stapleton, 1986). When such surgery is mentioned, seldom were reasons given for the specific indication, for example in Spengler (1980), who reports about a surgical breast augmentation for a woman who could not take hormones due to somatic intolerance. On the other hand, there are authors who qualified overall additional operations that patients had undergone as psychopathological symptoms -- in the sense of a Münchhausen Syndrome -- without being able to tell from their representations if any surgery would perhaps have been indicated (e.g., Hoenig et al., 1971). Additional surgery of this type was not compiled systematically in follow-ups.

There is also a wide spectrum of procedures with the FMT. This refers to the type, number, chronology and technique of the surgical procedures. The most frequent surgery was breast reduction, followed by ovarectomies and/or hysterectomies. In some works there are only reports about breast reductions (e.g., Wålinder, 1967; Randell, 1969). In another one, there is no mention of a breast reduction for a patient who had her womb removed and had penile (implantation) surgery (e.g., Alanko & Achté, 1971). The latter study shows -- in a small sample of only three males -- the non-unifomity of the reporting, which could mirror the non-uniformity of the proceedings. With a second patient there are three surgical steps mentioned (breast reduction, womb removal, penile [implantation] surgery); with the third they talk generally about sex reassignment surgery.

Regarding the removal of the internal sex organs, evidently it was not done uniformly. Some authors regarded this as superfluous; others recommended a supposedly gentle x-ray treatment (Vogt, 1968; Hoenig et al., 1971). Then again, others report that either only the ovaries or only the womb were removed; frequently all internal sex organs were removed. The employed surgical techniques were -- as a rule -- not mentioned in relation to the patients treated by a specific method, or when so, not in a statistically usable form. The same applies to surgical techniques for breast reduction and for the succession in which each of the surgical steps was used.

Very rarely there is a report about penile operations in general. The procedure with less secondary effects, the so-called clitoral mobilization, resp., the forming of the clitoris-penoid, was used by Wålinder and Thuwe (1975) in one case, in six out of 14 by Fahrner et al. (1987) and in about one-fourth of the males described by Eicher (1984); whereby in the two latter samples there may be overlaps. The more complex procedures that are not differentiated in follow-up studies by the employed (penile) surgical techniques (reforming of the labia by plastic surgery or a skin transplant from the lower arm) was evidently only used in 35 males (total number, not including possible sample overlaps; e.g., Benjamin, 1967; Money & Brennan, 1968; Randell, 1969; Money & Ehrhardt, 1979; Alanko & Achté, 1971; Wyler, 1978; Lothstein, 1980; Sörensen, 1981 b; McCauley & Ehrhardt, 1979; Fahrner et al., 1987; Kuiper & Cohen-Kettenis, 1988; Dudle, 1989; Pfäfflin & Junge, 1990).

Legal Sex Change
The judicial recognition of sex and gender change by approving the use of another first name already during the time of the Real-Life-Test and by the legal sex change after the finished treatment are important parts of the sex reassignment. It can cause some thoughts if "transsexualism as a historic project" in the sense of Hirschauer (1992 a, b) would exist if the gender assignment would have been treated less rigidly in the medical and judicial sense and a more open mind-set would have been used for gender reassignment. It can also be discussed if the legal sex change is part of the treatment or is to be viewed independently from it. In different European countries there are different models (Will, 1992). Under practical and individual viewpoints it is understandable that it is difficult to survive as men or women if their legal status is opposed to it (Augstein, 1992).

In the follow-up studies in the 1960s, all published before any special laws existed, there is more space assigned to the legal change than in later works and also their positions can be seen that influence the specific national rulings. Hertz et al., (1961) as well as Wålinder (1967) cite in passing the uncomplicated procedure of the name change as it was adapted later in the Swedish laws. Randell's ambivalent attitude about the operated who for him " are in fact nothing more than castrated males" (Randell, 1969, p. 375) probably largely influenced the legal practice in Great Britain. Walser's (1968) and Wyler's (1978) publications that do not only describe Swiss patients but also patients from the neighboring countries show the difference between the relatively easy Swiss solution and the then much bigger judicial problems in the countries of Italy, Austria and the Federal Republic of Germany (comp. Will, 1992). Legal sex changes were evidently unproblematic already in Singapore in 1977(Tsoi et al., 1977).

Most follow-up studies treat the questions of name and Legal sex change rather in passing. Everywhere where there is a report about patients marrying after surgery, one can come to the conclusion that name and legal sex changes were attainable. More specific studies about the consequences of the name change can be found at Hoenig et at. (1970 b) as well as Blanchard et al. (1985).