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Effectiveness Factors
The follow-up studies of the 1960s and 70s are
not differentiated -- with the exception of one
publication by Hoenig et al. (1970 b), which we will
treat separately -- in regard to the effectiveness of
single elements of treatment. The essential part of the treatment
for sex change, whose effectiveness was started to be
researched, consisted for them as "the
surgery." With regard to "the surgery",
all other aspects of treatment were of less importance,
even though Alanko & Achté (1971) highlighted with
emphasis that surgical treatment alone is therapeutically
inefficient. Only at the end of the 1970s was it started
to isolate single effectiveness factors from the overall
effectiveness and to research them.Disregarding all
methodological shortcomings in their work, the first to
demonstrate an independent effectiveness factor were
Meyer & Reter (1979), who identified continuous
contact with an organized research.program. The
guidance in the program at the Johns Hopkins Clinic in
Baltimore, about which they reported, was evaluation
rather than treatment. Patients who succeeded in having
regular contact to the research institute were clearly
better as patients who could not maintain such contact.
Improvements existed already before and, as such, were
independent of surgical treatment.
Similar results were found by Blanchard et al. (1983;
1985), Blanchard (1985) and Blanchard & Steiner
(1983) with their first multivariate cross-sectional
analysis of Canadian patients in different treatment
stages. They demonstrated with large samples that
psychological ailments and neuroticisms were
significantly reduced in the entire course of the
process of gender reassignment. They called the
process of gender reassignment "gender
reorientation." They developed for each of their
researches a slightly different gender reorientation
index and demonstrated, to the contrary of the
supposition of Meyer & Reter (1979), that the
measured positive changes were not merely the effect of
time passing (the sole aging or becoming an adult for the
examined patients, of whom only a partial sample were
treated with hormones or were operated), but the effect
of gender reorientation. The appearance and the
establishment of oneself in the other gender role, the
official name change and the entering into partnerships
were important factors that contributed to, besides
hormone treatments or surgery, a better psychological
adaptation.
These findings were confirmed by the research of
Kuiper (1985) and Kuiper and Cohen-Kettenis (1988) of The
Netherlands. According to the research, patients who in
the frame of a Real -Life-Test and being connected to
a treatment facility, have started at least a hormonal
treatment or already had undergone at least partial
surgery suffered less from gender dysphoria than
untreated patients. If the surgical treatment was
finished or not, or if it hadn't even started, was not
important in regard to the subjective well-being.
According to this, Fahrner et al. (1987) found, in
comparing three groups, resp., the evaluation of data
obtained in three measuring times, that already during
the time of the Real-Life-Test, statistically
significant positive changes compared to the time of the
start of the treatment manifest themselves. To the
contrary to the findings from The Netherlands, in those
patients who had finished the medical phase of treatment,
e.g., operated patients, additional positive changes were
measured in areas that were not considered in the Dutch
research.
As other effectiveness factors, counseling and
psychotherapy were demonstrated in the research of
Lothstein (1980) and McCauley and Ehrhardt (1984) of the
U.S.A., that probably were a factor in the research of
Meyer & Reter (1979) - only that these authors did
not differentiate of what the "contact to a research
program" consisted.
The surgical interventions, not surprisingly,
were also isolated as an effective factor in the
above-mentioned Munich research (Fahrner et al., 1987).
The work of Mate-Kole et al. (1990) in England three
years later confirmed this finding in comparison group
research, which, according to the judgment of all authors
of previous studies, was not adequate by therapeutic
reasons: Patients who were relatively immediately after
the diagnosis operated were at the time of the follow-up
study socially more active and showed less neuroticisms
than other patients who for a time period of at least two
years were kept on a waiting list and were not yet
operated.
For a long time the results regarding the question in
how far the cosmetic and functional quality of the
surgery contributed to the total results was
disputed. Generalized thought, single case studies, case
studies of the follow-up studies referred here to and
clinical impressions spoke for the hypothesis that the
total results must be worse the worse the quality of the
surgical results were (e.g., Benjamin, 1966, 1967;
Hastings, 1974; Eicher, 1984; Lindemalm et al., 1986;
compare to these the reference to suicide and regrets as
follows). In the same sense some authors report about
generally good results that they related to a well-done
surgical treatment (e.g., Pomeroy, 1967; Hore et al.,
1975; Zingg et al., 1980; Ball, 1981; Eicher, 1984;
Eicher et al., 1991). Finally, there are repeatedly
indications in the follow-up studies that patients were
either, despite "objective" satisfactory
surgical results, unhappy (e.g., Lindemalm et al., 1986);
resp., the other way around, in spite of
"objective" unsatisfactory surgical results,
were happy with the results of surgery (e.g., McEwan et
al., 1986; Blanchard et al., 1987). Already Randell
(1969) had observed that satisfaction, resp.,
dissatisfaction, with the gender change was independent
of the ability to function sexually. In our own follow-up
research we could not secure a relationship between the
quality of the surgical results and the satisfaction
(Pfäfflin & Junge, 1990). The contradiction of these
impressions and results is probably due to the diagnostic
and/or psychopathological and non-homogeneous samples, or
it depends on the length and quality of the previous
psychiatric/psychotherapeutic treatment and the measure
in which the possibility has been worked out that the
surgical results can stay far beyond the desired. It was
Ross & Need (1989) who demonstrated with research of
a psychopathological homogeneous group with the same
pre-treatment that an important part of the variation in
a general judgment depends on the quality of the surgical
results.
Long before the mentioned effectiveness factors were
isolated, Hoenig et al. (1970b) had tested the influence
of a juridical treatment measure (comp. Will,
1992), namely the name change and the change of the
National Insurance Card and found that patients with a
name change found work easier, stayed in the same job
longer and had less legal sentencing encounters with the
law. Even if the differences were not significant
statistically, they are equal to the impression of other
follow-up studies in which the positive or negative
consequences of name and legal sex changes were referred
to, depending if such were possible in the respective
national laws (e.g., Gunn-Sechehaye, 1964; Vogt, 1968;
Walser, 1968; Wålinder & Thuwe, 1975; Stürup, 1976;
Tsoi et al., 1978; Wyler, 1978; Ball, 1981; Pfäfflin
& Junge, 1990). In the studies of Blanchard (1985)
regarding the process of gender reorientation, the name
change represents an important effectiveness factor.
According to this, seven factors could be isolated
that contribute to the effect and effectiveness to
treatment of gender reassignment. Specifically (1)
continuous contact with a research program or a treatment
center; (2) living in the other gender role
(Real-Life-Test); (3) hormone treatment; (4) counseling,
psychiatric and/or psychotherapeutic treatment; (5)
surgical sex reassigning treatments, as well as (6) their
quality; and finally; 7) the juridical recognition of the
gender change by names and sex.
There is no statistically secure knowledge about how
long the first four factors had to be minimally to give a
good result. Control studies about variations of time
periods regarding this do not exist until now. As already
mentioned in the section about hormonal and surgical
treatments, most follow-up studies did not sufficiently
differentiate how long the patients had arranged their
lives to be recognized as a member of the other gender
before beginning their hormone treatment and how long
they were treated psychiatricially/psychothreapeutically
and hormonally. With regard to the Real-Life-Test, one
can only learn from the works that the length required of
it diverge significantly. Following the selection
criteria of the research and/or its indication as
shortest time period between one and three years is
mostly required, in one case even five years (Stone,
1977). But it is exactly Stone's work that is exemplary
for many other studies that sum-up under Real-Life-Test
everything that does not regard immediately genital
surgery e.g. the hormone treatment and cosmetic surgery.
Finally, the research of Mate-Kole et al. (1990) does not
give an answer to the question for successful time
periods for the treatment elements despite of three
measuring time points. This study only demonstrates that
another postponement of the surgical treatment with the
indication done by the rules of the art demonstrated to
be less favorable than a comparison with an immediately
following surgery.
Desired
Changes
In the follow-up studies as represented in
detail in section 3, treatment results and changes are
measured and evaluated under very different points of
view and with a wide spectrum of criteria and methods. In
the following, the results and evaluation are not
considered individually but are compiled into important
areas in which, with the follow-up studies, an effect had
been demonstrated. These effects can be ordered under a
gross simplification in four overlapping areas, namely
subjective satisfaction/unsatisfaction; mental
stability/instability; socio-economic functioning level
and finally, partnership and sexual experience.
Probably the most important change that is found in
most research is the increase of subjective
satisfaction. It contrasts markedly to the
subjectively unsatisfactory start position of the
patients. To describe the subjective satisfaction authors
have chosen different concepts. Some authors talked about
happiness (e.g., Benjamin, 1966; Kuiper &
Cohen-Kettenis, 1988); others talked about improved
patients or that patients were feeling better. This was a
global finding that, in the first two decades in a
general way, just was admitted and only regarding and
using the improvement of the scales of Hastings (1974) as
well as Hunt & Hampson (1980 a) could be measured
gradually and specified for the different living
situations. Regarding the increment of the subjective
satisfaction, all referred-to research agree, even those
authors who spoke most critically about the effects of
gender reassignment (Meyer & Reter, 1979; Lindemalm
et al., 1986).
In accordance to the opinion of the authors of the
newest review (Green & Fleming, 1990), the decisive
effect of the treatment of gender reassignment is the
subjective satisfaction and that is why the authors
consider it sufficient criteria. Other authors who also
consider this criterion of central importance consider it
necessary to compare it with other objective criteria
(e.g., Kuiper & Cohen-Kettenis, 1988). The
objectivization of satisfaction was done by regarding
categories such as mental stability, psychiatric
symptoms, clinical or test psychologically measurable
psychopathological characteristics, neuroticisms, number
of professional psychiatric contacts and
hospitalizations, suicidal tendencies, alcohol and drug
consumption, etc. One could add all this to the
frequently used concepts of psycho-social adaptation
and/or function.
If not in the same measure and not as uniform as the
subjective satisfaction for the total complex of mental
stability can be determined that, in the majority of
follow-up research, that include this area found also
more positive than negative results. Marked or
statistically significant were changes regarding mental
stability (e.g., Money & Ehrhardt, 1970; Hastings,
1974; Laub & Fisk, 1974; Wålinder & Thuwe, 1975;
Sadoughi et al., 1978; Spengler, 1980; Kröhn et al.,
1981; Sörensen, 1981 a; Fahrner et al., 1987; Mate-Kole
et al., 1990; Pfäfflin & Junge, 1990). Therein the
exclusively test psychological analysis has not been
regarded (comp. the overviews in Lothstein, 1984;
Pfäfflin 1993.
There is also research that could expressively find no
statistically relevant changes regarding mental stability
and related phenomena (e.g., Money & Brennen, 1968;
Hunt & Hampson, 1980 b) or could find this only in
certain partial populations (e.g., Walser, 1968; Stürup,
1976) or only for certain partial aspects, while other
partial aspects, for example, alcoholism, stayed the same
(e.g., Wålinder & Thuwe, 1975). While one can read
in between the lines of some authors that patients were
as stable after treatment, the more stable the
personality at the outset had been (e.g., Walser, 1968).
Lundström denies this (1981), explaining that the
psycho-sexual functioning level of the starting
personality is not of major importance for the success of
the treatment; or if there is, it is so extremely low
that improvement was not generally expected. The themes
suicidal tendencies and role reversal that belong to the
bigger complex mental stability will be discussed because
of their special importance further on.
Positive results are affirmed by most follow-up
studies regarding the socio-economic functioning
level. Under this category the ability to contact in
partnerships, with relatives, in the neighborhood and at
the work place are compiled, as well as the
socio-economic improvements. Improvements of the social
functional level based on clinical judgement or by means
of statistically significant comparison data are reported
in the works of Wålinder (1967); Vogt (1968); Walser
(1968); Randell (1968); Money & Ehrhardt (1970);
Hoenig et al. (1970 b); Ihlenfeld (1973); Hastings
(1974); Steiner (1976); Stone (1977); König et al.,
(1978); Turner et al. (1978); Meyer & Reter (1979);
Hunt & Hampson (1980 b); Lothstein (1980); Ball
(1981); Fahrner et al. (1987); Kockott & Fahrner
(1988); Mate-Kole et al. (1990); Pfäfflin & Junge
(1990) and Eicher et al. (1991). The measure of the
registered changes differs considerably from study to
study and even within one research, depending on the
regarded partial aspects of the very ample criteria here.
Hoenig et al. (1979b) found, for example, improvement in
the work situation and the diminishing of the crime rate,
but the treatment had no influence on the measure of
being dependent on national assistance. Discrepancies of
the mostly good results of the mentioned publications
were found in the sample of females described by
Sörensen (1981 a), mostly social decline and more social
isolation but not in the described sample of males
described by the same author (Sörensen, 1981 b). This
difference is in accordance with the majority findings
that the partial samples of males find their way better
generally than females.
The fourth major area regards partnerships and
sexual experience. In some samples these are
discussed in the follow-up studies in regard to
satisfaction, unsatisfaction and/or the psycho-social
function level - and without doubt there are overlaps.
Many follow-up studies indicate if there were -- before
and/or after treatment marriages -- and how long they
lasted. The simple fact of such a marriage or divorce
does not say anything about the quality of the
experience. The marriages contracted after finishing the
treatment are to be regarded only in the formal, not in
the qualitative sense, as a result of the treatment. The
stability and quality of the partnerships entered into in
the course or following treatment are mentioned
especially by Wålinder & Thuwe (1975); Blanchard
& Steiner (1983) and Kockott & Fahrner (1988).
The two last mentioned follow-up studies agreed that
males were more capable than females to maintain stable
and satisfactory partnerships. Apart from specific
follow-up study literature, partnerships of persons with
transsexual symptoms were researched in the publications
of Studer et al. (1989); Huxley et al. (1981); Steiner
& Bernstein (1981) and Steiner (1985).
More important seems to be the sexual experience that,
undoubtedly, represents an aspect of the general
subjective satisfaction/dissatisfaction, but was
researched separately in some follow-up studies. In his
first follow-up study Benjamin (1964 a) did not include
sexual satisfaction or orgasmic experience in the
evaluation areas because he regarded answers regarding
this area by women as unreliable. Also Pomeroy (1967),
who made the question of sexual experience the central
part of his follow-up study, distrusted the answers of
females to the orgasmic experience because he could not
fit them into his physiological image. In later follow-up
studies such information was taken more seriously (e.g.,
Wålinder (1967); Hastings (19749; Laub & Fisk
(1974); Steiner (1976); Hunt & Hampson (1980);
Lothstein (1980); Eicher (1984); Blanchard et al. (1987);
Kröhn et al. (1981); Fahrner et al. (1987); Ross &
Need (1989); Pfäfflin & Junge (1990); Eicher et al.
(1991). The four last mentioned follow-up studies found
that the sexual experience improved statistically
significantly and that most females experienced orgasms
regularly. Worthy of attention is that with males,
despite far more limited surgical possibilities in the
genital area, the sexual satisfaction after treatment was
statistically significantly higher than before treatment
(e.g., Junge, 1987).
Undesired Effects,
Complications, Risks
Complicated and undesired effects can happen in
every stage and regarding every type of treatment.
Because hormonal and psychiatric-psychothreapeutic
treatment is generally documented only in fragments one
cannot find a valid image regarding this in the follow-up
study reports. An exception is the most severe
psychiatric complication, the suicide, that is discussed
following the complications of the surgical treatment.
Overviews about complications about hormonal treatment
are, apart from the specific follow-up study literature,
in Asscheman (1989); Asscheman et al. (1988 a, b); Lips
et al. (1989). About single complicated courses in
connection with the difficulty or impossibility to change
name or personal data report, for example, Gunn-Sechehaye
(1964); Stürup (1976); Wyler (1978) and Ball (1981).
Complications Within Surgical Treatment. It is
difficult to draw a line between that counting as
complication within an unfinished treatment and what has
to be evaluated as a more-or-less bad treatment result.
It is readily agreeable that a treatment of an MFT is not
finished if only the penectomy and orchidectomy was done,
but no vaginal surgery had been initiated and with FMT if
no matectomy was done. It is more difficult if one
regards the formerly frequently used intervals between
the surgeries done at different times. In such cases the
unfinished treatment and the impossibility to change name
and legal sex can be a complication in itself or other
further complications that express themselves in
partnerships, in the workplace or also in the
psychopathological symptoms (for example, suicidal
tendencies). This is also valid for the penile surgery
that is desired by many FMT even if they follow the
advice of their treatment provider to wait until the
success expectation for such surgery is better.
The spectrum of the immediate complications from
surgery is widely dispersed. Some authors mention intra-
or immediately post-surgical complications such as
haematomas, abscess forming, bleeding, infections, etc.,
that have to be viewed as general surgical complications
and not as specific complications in sex reassignment
surgery.
Others indicate specific complications in MFT
operations, among which necrosis and partial necroses of
the vagina and labia are found, as well as fistulae in
the bladder and intestines, stenosis in the end of the
urinal tract and finally too-short and/or to-small
vaginas that principally require additional surgery. From
surgical breast enlargements, infections and capsular
fibrosis are mentioned.
Among the worst complications in FMT operations for
breast reduction are nipple necrosis and ugly scarring.
With clitoris-penoid and phallus operations there are
urinary tract stenosis and fistulae and, also necrosis of
theneo-phallus. Besides this, there can be rejection
reactions the silastic-testicle prosthesis and to a
dehiscence of the scrotal suturemay occur.
If these complications cannot be resolved by follow-up
surgery, either because it cannot be done technically or
because the patient does not want any more surgery, then
the surgery must be valued as unsatisfactory, resp., bad
results. Already Benjamin noted in some of his
publications that in his samples there were series of
complications that could have been solved principally so
that the results in general could have been much better
if the necessary follow-up surgery had been performed.
McEwen et al. (1986) said that the rate of complications
was 35%, but also said that most complications could be
solved. It is important to inform the patients that the
results are not always perfect.
By far, not in all follow-up study reports in which
complications are mentioned at all are there specific
indications. In some works, it is only mentioned globally
that there were many complications and/or many corrective
treatments (e.g., Benjamin, 1964 b; Money & Ehrhardt,
1970; Wyler, 1978; Sörensen, 1981 a; Pfäfflin &
Junge, 1990). Stone (1977) even said that most patients
of his sample had complications. Other works quantify at
least some of the severe complications (e.g., Benjamin,
1966; Zingg et al., 1980; Kröhn et al., 1981; Wiegand,
1984; Dudle, 1989). Eicher (1984) reported unsatisfaction
regarding the local finding and interference of the
sexual capabilities of those 10% of females of his sample
who suffered from vaginal stricture and/or shortening and
added that these females, where the local finding was
revised successfully, were satisfied afterwards.
One older work, Laub & Fisk (1974), reported over
40% complications in those females operated by them, but
also counted, for example, the necessity of blood
transfusions as complications. By comparison, they found
in females primarily operated elsewhere a complications
quota of 92%. This frighteningly high value is due to the
effect of the sample that almost exclusively patients who
had complications in their first surgery came (to them)
for secondary surgeries. A similar comparison was done by
Jayaram et al. (1978). Hore et al. (1975) reported
exclusively about secondary surgeries and the removal of
previously caused complications and improvements of bad
surgical results.
Suicide Rate: In 39 of the follow-up studies
and reviews referred to here, the suicide rate of
patients is themed. The spectrum reaches from very global
indications about quantifications that do not distinguish
enough between depressive moods, thoughts of suicide,
threatening suicides, suicidal attempts and suicides, to
very specific indication regarding the respective sample.
Alanko & Achté (1971) estimated that the risk of
suicide in transsexualism is very high. According to
Hastings (1974, p. 335) "most" of the patients
compiled in his follow-up study had attempted suicide. In
the group analyzed by Wålinder (1967) he found in the
anamnesis in 68% of the patients depressive moods, in 49%
suicidal thoughts and in 16% suicide attempts. All these
indications refer to patients before or at the beginning
of treatment.
Regarding the suicidal tendencies after surgery, the
specifications of these indications in the follow-up
studies and reviews are just as widely dispersed:
According to Hunt & Hampson (1980 b), many said
spontaneously and with great emphasis that they were only
alive because of the sex reassignment. Very vaguely
quantified, Hastings (1974) reported something similar,
namely, that every second female, in accordance to her
subjective judgement, was saved from suicide by the
surgery. Kröhn et al. (1981) spoke of a blatant
diminishing of pre-suicidal tendencies, but only
quantified the frequency of post-surgical suicidal
thoughts reported.
Three works contain exclusively general indications
about suicidal tendencies. In seven works only
indications to pre-surgical suicidal tendencies can be
found, in 11 publications exclusively corresponding
indications for the katamnesis time period. Pre-post
comparisons are contained in 13 works. Because of sample
overlapping the total (number) of follow-up study
subjects cannot be exactly ascertained. Because of this,
only something approximate about the magnitude of suicide
in patients with transsexual symptoms can be deduced.
Corresponding intents were made by Pauly (1965, 1981) and
Lundström et al. (1984) in their reviews, with the
result that the post-operative suicide rate for females
is 1.9% and for males, 0.8%. (Lundström et al., 1984; in
where also they counted the psychotic patients described
by Stürup in 1976 who were not operated and cases that,
in accordance to the judgement of the primary authors --
Randell (1969) and Wålinder & Thuwe (1974) -- were
not or only circumstantially in a causal connection with
the sex reassignment.)
To determine the pre-surgical suicidal tendency the
use of a bigger sample description independent of
follow-up literature is useful. Among 479 MFT and 285 FMT
who were examined in the Gender Disphoria Program in Palo
Alto, California (USA), 25.5% of the MFT and 19% of the
FMT immediately before or a longer time before the
treatment started had attempted suicide (Dixen et al.,
1984). In the same dimensions are the figures from The
Netherlands. According to them, of 168 MFT, 19.3% had
attempted suicide before treatment start and of 55 MFT,
18.6% had tried it prior to treatment (Verschoor &
Poortinga, 1988). In 18 of the follow-up studies referred
to here are indications about the pre-operative suicidal
tendencies. In a major number of publications, it is
around 20% or even higher (e.g., Hoenig et al., 1971;
Wålinder & Thuwe, 1975; Wyler, 1978; Sörensen, 1981
a, b; Kuiper & Cohen-Kettenis, 1988; Dudle, 1989;
Wiesbeck & Täschner, 1989; Stein et al., 1990).
Throughout all, one can find the difference between the
relatively high suicidal tendency of the MFT and the
relatively low one of the FMT. An exception is the group
of FMT described by McCauley & Ehrhardt (1984), in
which 6 of 15 (40%) of patients had attempted suicide
before treatment start. This particularity is probably
due to the fact that the authors, in long-time therapies,
received more information regarding this than other
researchers who could refer only to files or one-time
follow-up examinations. This could be an indication that
suicide attempts, in reality, happen more frequently than
indicated in follow-up studies.
In publications that describe courses that are from
further back, suicide threat and self-mutilation to
achieve the surgery play an important role (e.g.,
Hastings, 1974; Stürup, 1976; Wyler, 1978). The only
author who declares such threats and also extortion
attempts as explicit reasons for removal from the
treatment program is Ball (1981). Two authors reported
about patients who attempted suicide one or more times as
a reaction to being told that sex reassignment surgery
was not an adequate measure for them (König et al.,
1971; Lundström, 1981).
Suicide was committed by four MFT after the
start of treatment but prior to surgery (Stürup,
1976; Spengler, 1980; Eicher, 1974; Wiegand, 1984) and
five FMT (Sörensen, 1981 b; Lundström, et al, 1981).
Two authors contrast these indications explicitly by
emphasizing that, among the operated of their samples, no
more suicides were committed (Sörensen, 1981 b; Eicher,
1984). One suicide of FMT (Lundström, 1981), resp., one
of MFT (Spengler, 1980, personal report) were seen as
immediate reactions to the announcement that admittance
to surgery would not be forthcoming. One patient had
abandoned the desire for the surgery and, because of a
paranoid psychosis, committed suicide (Stürup, 1976). In
three other deaths it cannot be discerned from the source
if they had already been operated or not (Kuiper &
Cohen-Kettenis, 1988).
Eighteen works report about suicide attempts after
surgery. Insofar as motives for it are mentioned,
primarily, crises in the relationships/partnerships is
mentioned (e.g., Kando, 1973; Hastings, 1974; Stürup,
1976; Hunt & Hampson, 1980b). In second place are,
especially with males, bad results of the penis
operation, resp., the circumstance that such were not
done (Money & Ehrhardt, 1970; Hoenig et al., 1971).
Sörensen (1981b) describes, as part of his follow-up
sample, a man who was not approved for the surgery
because he was pre-psychotic. Then he underwent surgery
somewhere else and six months later, tried to commit
suicide with pills. Some authors say how many of the
patients with post-operative suicidal tendencies
attempted suicide before (Wålinder & Thuwe, 1975;
Kuiper & Cohen-Kettenis, 1988). Other authors remark
that patients who had suicidal tendencies before surgery
reacted in later partnership crises only with depression
but not with suicide (Wyler, 1978; Spengler, 1980) or
that suicidal tendencies were observed only in the year
after surgery or as long as bad surgical results were not
corrected, but after that disappeared (Lothstein, 1980;
Stein et al., 1990) .
There are reports of a total of 16 deaths that
happened after surgery, in which it is questionable if
each was a suicide and if the reason was connected to
transsexualism (Benjamin, 1964b; Randell, 1969; Gandy,
1973; Ihlenfeld, 1973; Wålinder & Thuwe, 1975;
Sörensen, 1975a; Blanchard et al., 1985; Lindemalm et
al, 1986; McEwan et al., 1986); in these works there are
actually reports about 17 deaths, but one of the females
mentioned by Benjamin is also mentioned by Ihlenfeld
(comp. the section about sample overlaps). There are 14
females and one male (Ihlenfeld, 1973) and one patient
with not gender specified (Gandy, 1973).
In accordance with the estimate to the primary
authors, it is questionable in five cases if they were
suicides or accidental medication or drug overdoses
(Benjamin, 1964b; Ihlenfeld, 1973). Of the remaining 11
cases, three were in no immediate relation with the
problems of gender identity, in the judgment of the
primary authors, but were in relation to either the very
large surgical complications of a patient who already had
suicidal tendencies (Wålinder & Thuwe, 1975), with
major complications after operations that did not have
anything to do with gender reassignment (Blanchard et
al., 1985), or with the loss of work and a partnership
crisis (McEwan et al, 1986). With two other females,
additional psychiatric factors had a decisive role
(Randell, 1969). These two females, as well as another
female (Sörensen, 1981a) and a single male (Ihlenfeld,
1973) had undergone surgery against the specific votum of
the treating physicians who did not deem the surgery as
indicated, but had undergone surgery abroad or in other
treatment facilities. The remaining four patients about
whose motives nothing is know: One suicide was committed
shortly after the surgery (Lindemalm et al, 1986); one in
contrast to the impression of the last meeting of the
examining physician with the patient (Gandy, 1973); and
with two females it is rermarked that they did not belong
to the core group of transsexuals, were relatively old at
beginning of treatment and were judged prognostically as
rather critical (Sörensen, 1981a).
The data can be compiled in the direction that suicide
attempts are frequent in patients with transsexual
symptoms and that about every fifth patient has tried
suicide before starting treatment at least once. As a
tendency the rate is higher with MFT than with FMT. This
difference is found for the anamnesis, as well as for the
treatment and katamnesis. In the course of treatment, the
relative number of suicide attempts decreases in
accordance with the agreed-upon judgments of the authors
who make differentiated statements. Which treatment steps
(psychiatric-psychotherapeutic, hormonal, surgical
treatment) have a positive effect cannot be
differentiated based on the figures alone.
The numbers of reported suicides in the follow-up
studies are, in sum, about twice as high for
post-operative patients compared to pre-operative
patients - but not the suicide attempts. This result is
due, primarily, to a distortion of the samples. Mostly in
the publications the course of a partial sample of the
operated was examined because patients who were not
treated in accordance to their wishes in treatment
facilities went to other treatment facilities and were
lost for the follow-up studies. Reliable data about what
happened to them long-term and especially how the lethal
suicidal tendency was in this group is hardly available
(exception, for example, Lundström, 1981). Besides this,
it is to be regarded that with increasing age, the
possibility increases that a suicide attempt ends
lethally (Häfner, 1991). Finally, the examination of the
case studies show that post-operative suicides had
decisive factors other than gender identity problems or
that the sex reassignment surgery was considered as not
indicated by experienced examiners or that the treatment
was not sufficient.
On the other hand, it would be inadequate to make the
indication for gender reassignment only under the aspect
of the suicide prophylaxis. A corresponding styled case
is reported by Herschkowitz & Dickes (1978) to
exemplify the treatment did not do what it promised.
Simplification of this type can be abused easily in
social-political discussions, for example, the question
if the health insurances have to cover treatment costs
(e.g, Ehrhardt, 1985, citing Herschkowitz & Dickes,
1978). There is no question that, in the treatment of
highly depressed and suicidal patients with transsexual
symptoms, patients have to be treated
psychotherapeutically and psychiatrically before the
indication for sex reassignment surgery is made.
(Wålinder, 1967 and Eicher, 1984 found depressive crises
in the anamnesis of over 60% of patients examined by
them; comp. Langer, 1985.)
Role-reversal / regrets: If one sums all
cases of "relapses" in all follow-up studies,
20 MFT can be found (Hertz et al, 1961; Benjamin, 1966;
Walser, 1968; Randell, 1969; Alanko & Achté, 1971;
Hastings, 1974; Wålinder & Thuwe, 1975; Stürup,
1976; Wålinder et al, 1978; Ball, 1981; Kröhn et al,
1981; Lindemalm et al., 1986) and five FMT (Benjamin,
1966; Money & Ehrhardt, 1970; König et al, 1978;
Meyer & Reter, 1979; McCauley & Ehrhardt, 1984).
As already said with suicidal tendencies, figures cannot
be made in percents, because the numbers of examined
patients cannot be determined exactly due to sample
overlaps. Insofar as case descriptions exist, they do
however allow a differentiated viewpoint.
Role-reversal / rgrets in MFT: First, it is to
be determined that, of the 20 patients, two are described
twice (Wålinder & Thuwe, 1975; Wålinder et al.,
1978). Two other patients had only begun hormonal
treatments and were not operated, not belonging to the
real "relapses;" one of them had a religious
conversion (Hastings, 1974); another one abandoned the
wish for surgery and developed a paranoid psychosis and,
in its course, committed suicide (Stürup, 1976). As
"passing" repentance cases with short, single
or intermittent cases of role-reversal, two patients are
described (Ball, 1981; Kröhn et al, 1981), where the
case described explicitly by Ball (1981) special
inheritance rights that greatly complicated the
circumstances. In one case it is only mentioned that the
patient had the intention to live as a male, but left it
open if really done (Benjamin, 1966).
In examination of the other 14 cases, three factors
contributed greatly to the "relapses." The
first factor was the differential diagnostic
indication for surgical treatment; the second is
tightly related to the contextual important criterion if
the life in the desired gender role was rehearsed long
enough in the Real-Life-Test; finally, the third
regards the extent and quality of the surgical
procedures . We will regard the first mentioned
factor first.
At least four patients developed psychoses or paranoid
reactions (Hertz et al., 1961; Alanko & Achté, 1971;
Hastings, 1974; Wålinder & Thuwe, 1978), in which it
has to be asked if this development could not have been
foreseen with a sufficiently long pre-operative
psychiatric treatment, especially because the patient
described by Hastings (1974) did not fulfill in any way
the normal indication criteria. He was noticed more than
once for violent crimes, was an alcoholic, had tried to
cut off his penis with a shaving blade, castrated himself
later and tried to extort vaginal surgery with a threat
of suicide. Also one of the patients described by Stürup
(1976) had multiple auto-castration attempts behind him,
that, according to Springer(1981), were more likely a
psychotic than a transsexual development. His treatment
was contradictory: First, he was given male, and later,
female hormones. Surgically only a castration was done,
but no vagina was formed. The patient had not mentioned
that he was married, so he could not attain a name change
and lived as a female with male identification papers. At
the time of the follow-up study, 19 years after the
operation, he lived again as a male but was convinced
that the operation was right and only regretted that it
had been performed so late in his life.
In at least three patients, the requirement of the
adaptation to everyday life experience in the opposite
gender role was not regarded. They were operated without
ever testing the other gender role in their lives
(Walser, 1968; Alanko & Achté, 1961). The already
mentioned psychotic patient described by Hastings (1974)
would also belong to this group.
As a third important factor that can conduce to
relapses, the authors mentioned the unsatisfactory
application of surgical possibility and unsatisfactory
surgical results. Two patients were only
orchidectomized and the penises remained, a vaginal
surgery was not done and the patients were bitter that
they could not achieve more (Walser, 1968; Stürup,
1976). With others, up to five years passed between the
orchidectomy or penectomy and the vaginal operation
(Hertz et al., 1961; Alanko & Achté, 1971). Insofar
as the surgical results are described, they are in almost
all "relapses" unsatisfactory (Hertz et al,
1961; Benjamin, 1966; Randell, 1969; Wålinder &
Thuwe, 1975; Lindemalm et al, 1986).
Role-reversal in FMT: With high probability,
one of the five patients is reported about twice (Money
& Ehrhardt, 1970; Meyer & Reter, 1979). The
patient is one who circumvened the relevant treatment
facility to obtain the surgery. Multiple penis surgeries
were unsuccessful, resp., had miserable results. The
patient was drug-addicted and repeatedly suicidal and
lived sometimes as a male, sometimes as a female.
According to Meyer & Reter (1979), the patient only
wanted the failure-of-a-penis removed, but did not
question the other steps of the gender reassignment. The
citing of the other patients is very sparse. One
regretted the surgery, but it is not clear if he, like
the patient described by McCauley & Ehrhardt (1984),
returned to the original gender role (König et al.,
1978). One patient had tried to live as a male after
surgery without success. This patient had later a breast
enlargement surgery (Benjamin. 1966).
A publication of Wålinder et al. (1978) dedicated
previously referred-to work especially to the theme
relapses, resp. regrets. The authors wanted to isolate
the unfavorable factors that were in the personality of
the patient or in the social environment. They
highlighted that only the amassment, but not the
existence of single prognostic unfavorable factors, was a
contra-indication for surgery and the differentiated
viewing of the single case had precedence. Citing
symposium presentations at the 5th International Gender
Dysphoria Symposium (1977) -- that are not accessible to
us -- Sigusch et al. (1979) mentioned the number of a
total of 44 "relapses" - exactly twice as many
as we could find in the follow-up studies. There were no
extensive and differentiating indications as to the
stadium of treatment that the patients were in, if and
which indication criteria were regarded, if the
repentance was in crisis-like stressful situations, or if
it was a permanent role-rereversal situation or even an
attempt to reverse the surgery.
According to the aforementioned follow-up study
literature, "relapses" are very rare, in FMT
even more so than in MFT. In light of these case samples,
the impression was gained that in most cases -- with
sufficiently careful differential diagnostic (testing),
sufficiently long tests of life in the other gender role
and a better use of surgical possibilities --
role-rereversal could have been avoided. It seems to us
worthy of mention that single patients who were operated
with disregard of these three factors and later
experienced themselves again as members of their original
gender, worked through these painful detours in a way
they could stabilize themselves (comp. examples in
Benjamin, 1966; Alanko & Achté, 1971; Wålinder
& Thuwe, 1975; Stürup, 1976).
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Historic Papers 
