Differential Indication

• Personal Factors
• Social Factors
• Treatment-specific Factors

Besides testing if and how and under what circumstances a treatment is effective, it is an important purpose of follow-up studies to extract differentially on whom it is effective. This is the traditional diagnostic question that corresponds to the principle that before every therapy there has to be a diagnosis.

A special thing about gender reassignment is that the diagnoses transsexualism and gender dysphoria were developed parallel and in interchange with treatment possibilities. Treatment was done already in the first third of this century - when there were neither generally accepted or binding criteria to characterize the mentioned phenomena nor corresponding diagnoses. Diagnostically and therapeutically, it was new territory and treatment indications were done "with the greatest caution" (Benjamin, 1967, p 117) in "carefully selected cases" (Benjamin, 1964a, p 111). This and related formulations were used almost like a formula in many subsequent follow-up studies (e.g., Stone, 1977; Blanchard et al., 1985) wherein many times it was not made clear under which viewpoint the patients had been selected and what "care" implied (e.g., König et al., 1978; Täschner & Wiesbeck, 1988).

In the 1960s and 70s it was tried to formulate the diagnoses transsexualism and gender dysphoria, as well as indication criteria for surgical treatment, more clearly. It could be based, then, on many single case studies and first follow-up studies with bigger samples (Pauly, 1965, 1968, 1974a, b; Wålinder, 1967; Wålinder & Thuwe, 1975). It seems that two diagnostic guidelines were formed, out of which the first was more oriented on diagnostic differentiation and the second more on pragmatic action perspectives.

In European countries, where an older tradition of surgical sex reassignment existed, the orientation was more towards the diagnosis transsexualism, that, corresponding to a classic illness model, was understood more or less as a nosological entity and -- in the tradition of other psychopathologic classifications - was to be clearly separated by differential diagnostic from other psychopathologic phenomena. Who was transsexual, was transsexual in that sense in one's being. The demand that before an indication to treatment a sure (Wålinder & Thuwe, 1975) or even an absolutely sure diagnosis (Hoenig et al., 1970a, b, 1971; Alanko & Achté, 1971) had to be established is to be seen with this background.

To the contrary, especially in the North American countries, the flowing borders to other psychopathologic phenomena were more strongly highlighted and the treatment wishes of patients were regarded more pragmatically. The transsexual syndrome was regarded as the strongest form of a widespread spectrum of gender identity disturbances (Benjamin, 1966). The dichotomous differentiation between "primary" and "secondary," resp., "true" and "false" transsexuals was broken. For this spectrum, Fisk (1973) made the new diagnostic category Gender Dysphoria - as an all-inclusive description. The special thing about the new diagnostic collective description and the treatment in programs of gender identity clinics was that a patient could sometimes become transsexual in a course of treatment that mainly consisted of experiencing and practicing those behaviors considered necessary for a good "adaptation" and a good "functioning" as a member of the other gender, and less working out the conflicts or intrinsic personality characteristics. Patients who were already "transsexuals" -- those patients under category A in the follow-up study of Laub & Fisk (1974) -- needed, besides hormones and surgery, no other treatment; patients of categories B and C had to absolve an ample program. Depending on how successfully they passed, they qualified as surgery candidates or not. Gandy (1973) as well as Laub & Fisk (1974), who belonged to the same working group, showed basic differences to European tradition strongest when they highlighted that a diagnostic classification for treatment indication was much less important than the successful absolving of the adaptation to everyday life test.

There were and there are overlaps between both traditional lines. The diagnostic gender dysphoria was included in the European literature and the treatment implication connected to it influenced the European treatment practice, even if this cannot be precisely demonstrated on single follow-up studies. Most clearly, as shown in the titles and contents of the publications of Wålinder (1967) and Wålinder & Thuwe (1975), they talked about transsexualism and transsexuals and the study by Lundström (1981) -- stemming from the same Swedish institution-- talked about patients who were diagnosed first not as transsexuals but as gender-dysphoric - some of whom later became transsexuals or at least became adequate surgical candidates. Also the treatment practice in The Netherlands seemed to be marked by the concept of gender dysphoria, even though patients treated with hormones and surgery were classified diagnostically as transsexuals (Kuiper, 1985; Kuiper & Cohen-Kettenis, 1988).

The guidance diagnoses transsexualism and gender dysphoria have in common that they reference themselves. Independent of which of these diagnostic labels was given preference in the different treatment facilities, at the end it was the treatment provider who decided whom to refer to psychiatric, psychotherapeutic or surgical treatment and in each treatment facility there were explicit or implicit selection criteria for referral to surgeons, resp., the admittance to surgery. This was also valid when patients attained hormones on the black market or if they left a treatment facility that did not bow to their wishes for surgery in order to have surgery in another city or country.

Because in most publications the criteria for admittance to a treatment program and the indication recommendation extracted from follow-up studies regard each other like a circle and most indication recommendations do not describe prognostic ally favorable starting circumstances with a prediction value that is demonstrated empirically in the sense of a statistical test, it seems to us most sensible to regard together the selection criteria, indication recommendations and the few differential indication viewpoints considered secured. Therein three groups of selection, resp., indication criteria, can be separated; namely, first, those factors centered primarily on the person /personality of patients, second, those that mostly regard the social situation of patients and, finally, those in connection to the treatment providers and treatment programs. Among the three areas there are overlaps that will be remarked on in the following discussion.

There is extensive agreement that not only an acute, but also a remittent psychosis is normally a contra-indication for treatment for gender reassignment. In many of the samples described here, patients who suffered from psychoses were excluded from the start (e.g., Benjamin, 1964a, 1967; Money & Ehrhardt, 1970; Arieff, 1973; Hastings, 1974; Laub & Fisk, 1974; Wålinder & Thuwe, 1975; McKee, 1976; Stone, 1977; König et al., 1978; Hunt & Hampson, 1980b; Lundström, 1981). Some authors say that a psychosis is an absolute contra-indication (e.g., Alanko & Achté, 1971; Hoenig et al., 1971) and others treat it as relative contra-indication, resp., a risk factor (e.g., Wålinder & Thuwe, 1975).

As other psychopathologic exclusion criteria,the following are named: epilepsy (e.g., Wålinder, 1967; Money & Ehrhardt, 1970); psycopathies and personality disorders (e.g., Randell, 1969; Hoenig et al., 1971); sociopathies (e.g., Arieff, 1973; Hastings, 1974; Laub & Fisk, 1974); all forms of mental handicaps (e.g., König et al., 1978; Hunt & Hampton, 1980b); borderline disorders (e.g., Alanko & Achté, 1971; Stone, 1977; König et al., 1978); neuroses (e.g., Stone, 1977); sexual deviations (Lundström, 1981); alcohol and drug addictions (e.g., Hoenig et al., 1971; Arieff, 1973; Stone, 1977) and suicidal tendencies insofar as manifested in the form of suicidal threats (Randell, 1969; Stone, 1977; Ball, 1981). Regarding self-mutilation, they were valued in some of the older publications as indications for an operation, which was questioned fundamentally by Springer (1981). Many case examples in the follow-up studies show that the exclusion criteria were not maintained in hardly any samples and when they were not maintained, the results were statistically not fundamentally better or worse than anywhere else. In one study it was experimented to treat a sociopath with the aid of a sex reassignment that had the result that the failure was generalized by the treatment providers and it was a disadvantage for the atmosphere in the treatment team (Hastsings, 1974). The criteria are mostly mentioned placatively in most folow-up studies. Behind some of the diagnoses, (e.g., neuroses, borderline disorders, sexual deviations) are nosological concepts that other authors generally regard as implicit to transsexual symptoms so that it does not make any sense to oppose them to transsexualism.

If one views the results of follow-up studies, noting that -- additionally to transsexual symptoms -- psychopathologies exist; it can be concluded that the treatment results were proportionally better the less psychopathological traits the original personality had (e.g., Lundström et al., 1984; Wiegand, 1984; Dudle, 1989) . Viewing the positive side, this signifies for prognosis and, as that, for the indication: a favorable result is attainable easier the more psychologically stable a patient was at the beginning of treatment. Corresponding to this triviality, some authors demand, as indication condition, explicitly a very high mental stability or high ego-strenght (e.g., Walser, 1968; Randell, 1969; Alanko & Achté, 1971; Stürup, 1976; Hunt & Hampson, 1981b; Sörensen, 1981a, b). Stone (1977) saw alone in the circumstance that somebody could need a psychiatrist as a contraindication. In accordance to Lundström's study results, the psycho-social function level is only then unfavorable if it is extremely low (Lundström, 1981; Lundström et al., 1984).

For FMT it is explicitly said in some research -- and implied in many treatment facilities -- that some biological constitution criteria was used to make the prognosis: that the treatment provider tried to gain the impression of the patient to be able to live more or less unnoticed as a female based on his body form and dimensions and expressions to have enough predispositions (e.g., Benjamin, 1964a, 1966, 1967; Wålinder, 1967; Hunt & Hampson, 1980b; Wålinder & Thuwe, 1975; Eicher, 1984). These problems did not reach the same extent for FMT because the hormonally-caused changes of secondary bodily hair and voice level better facilitated more recognizable exterior changes, thus facilitating an inconspicuous life as a male. Social clichés have an important role in the evaluation of these aspects. In clinical work the discussion of such factors is important because self-awareness and reality testing can be sharpened. In the follow-up studies they are generally documented insufficiently to draw conclusions that are relevant to the indication by them.

Secure data about how the age of the patient influences the prognosis is not attainable in the follow-up studies. The findings are contradictory. In most treatment facilities where we have data, the becoming of age was a prerequisite, probably because of judicial reasons. Laub & Fisk (1974) accepted only patients ages 21 to 58. König et al. (1978) excluded a patient because of his high age, but did not specify how old he was. Lundström et al. (1984) found a correlation between the age at first contact to the treatment facility and the diagnostic classification. Patients who were older than 30 at first contact were frequently diagnosed as secondary transsexuals and prognosed that they, to the contrary of primary transsexuals, could live without surgery and that is why they recommended great caution for the surgery indication. Arieff (1973) and Wiegand (1974) also judged advanced age critically regarding the treatment indication. Eicher (1984) thinks that the prognosis for average younger patients is better than for older ones and says in founded exceptions the indication for surgery could be done before the age of 18. Ihlenfeld (1973) and Stürup (1976) found, to the contrary, that also older patients could gain from treatment and decided that the age alone should not be an exclusion factor. Away from the follow-up study literature, Gooren (Kamprad & Gooren, 1991) recounts the case of a patient who underwent surgery at the age of 78.

Social Factors
Fundamentally, the social criteria that many authors see as favorable or unfavorable regarding the prognosis mirror those factors that contribute to mental stability or instability. If somebody can establish over a long period of time his/her claim to be a member of the other gender in a way that he/she gets along well socially and can earn a living, then this requires a not inconsiderable amount of mental stability. In almost all follow-up studies of the last two decades and also in most of the older publications, a successful passing of the adaptation to the other gender role and the financial self-sufficiency as preconditions for the surgery indication (e.g., Benjamin, 1964a, 1966, 1967; Randell, 1968; Money & Ehrhardt, 1970; Hunt & Hampson, 1980b; Ball, 1981). It was proven in a small portion of the publications that these requirements were fulfilled. To the contrary, much of the transmitted data in many cases indicates that this was only true for partial samples and that unemployment and dependency on social welfare were predominant especially among MFTs (e.g., Hoenig et al., 1970a, b, 1971; Pfäfflin & Junge, 1990). In some samples patients with a bad social anamnesis were explicitly excluded from treatment (e.g., Arieff, 1973; Wålinder & Thuwe, 1973; Lundström, 1981). Criminal convictions that are not related to transsexualism (Eicher, 1984), a criminal record in general (Money & Ehrhardt, 1970) or at least severe criminality (Hastings, 1974) also conduce to an exclusion of treatment programs. Case studies about unfavorable courses, suicidal tendencies and role-reversal, as well as general clinical experience, affirm the high importance for the prognosis for the factor social stability. Sociopathies, illegal drugs, drug and alcohol dependency are not favorable pre-conditions for treatment. To evaluate these factors it is decisive if the corresponding problem areas are evaluated just once and pointedly in the first examination that is decisive for the indication for hormonal and surgical treatment or if other possibilities of professional help are considered that -- if they were effective -- can lead to more positive prognostic judgments.

Different authors evaluate differently if patients are married and/or are parents. Some saw in that or in heterosexual experiences or in strong sexual interests prognostically less favorable factors (Wålinder et al., 1978). Taking this up, Blanchard et al. (1989) questioned 50 females and 61 males at least one year after finishing the surgical treatment with a routine questionnaire that also included questions about if the subject would subject him/herself to the surgical treatment for sure or rather not, if the decision would have to be made again. These questions were answered with no by all males and by 36 females who felt sexually attracted to males. Of 14 females whose sexual desire was directed towards females and whom the authors called heterosexual according to their chromosomal sex, four answered the question in the positive. The authors reached the conclusion by this that the probability of "regrets" with heterosexual MFTs is larger than with homosexual MFTs as well as FMTs. The figures were small and the classification of females to a heterosexual or homosexual orientation was problematic; the question was hypothetical and the "regret" did not find an expression in the so-called re-conversion desire so that the examination results hardly can have a value for single case decisions. Some authors thought that heterosexual experiences (Tsoi et al., 1978) and previous marriages (Laub & Fisk, 1974) were exclusion reasons. The hardest was Stone's opinion (1977) who thought that the practice of genital sex was already a contraindication. Some insisted on divorce (e.g., Money & Ehrhardt, 1970) and then others on the presentation of an agreement of the spouse (e.g., Eicher, 1984). Many other authors did not think that the measure of sexual activity or experience with marriage and parenthood were fundamentally unfavorable, this is evident because in many publications there are reports about previous marriages of the patients.

Similarly widespread is the evaluation for prostitution. While some authors measure the success of the treatment with the diminishing of prostitution or promiscuous attitudes (e.g., Hoenig et al., 1970 a, b, 1971); others thought that the circumstance that somebody earned his/her keep from prostitution as failing the adaptation to Real-Life-Test and as reason to exclude the individual from treatment (e.g., Ball, 1981). To the contrary, prostitution was no reason to exclude an individual in other studies and was not valued negatively (e.g., Benjamin 1964a, 1966, 1967; Zingg et al., 1980) or it was even for the majority of a sample the source of income (Tsoi et al., 1978) or the interest in it was valued as practical, professional interest and demonstrated to be prognostically rather favorable (e.g., Wiegand, 1984). Different valuing of this form of social behavior in different follow-up studies demonstrates it is not usable as a prognostic indicator.

Analogous findings are also true for homosexual and sexually deviant behaviors- like cross dressing in a sexually arousing manner, etc. In some treatment facilities it was strongly enforced that patients with homosexual attitudes were not included (e.g., Hastings, 1974; Stone, 1977; Lundström, 1971) or it was demanded that they break contact with the sub-culture (e.g., Ball, 1981) or deny homosexual behavior personally and for the partner (Stone, 1977). To the contrary, Blanchard et al. (1989) found in the partial sample of subjects with heterosexual orientation more regrets than in those with homosexual orientation. For most authors, the gender(s) of previous or later sexual partners was(were) irrelevant regarding the judgement of the success of the treatment. Laub & Fisk (1974) found, in comparing three sub-groups of their sample, no differences regarding treatment results if the patient from the beginning on felt transsexual or felt and acted as a homosexual or a transvestite.

Treatment-specific Factors
In comparison to the personal characteristics and social factors that characterize the patient and his/her environment, those factors from the treatment provider or treatment facility influencing the course of treatment positively or negatively are reflected much less carefully. That treatment conditions and attitudes of the authors essentially form the indication, type of treatment and results and their interpretation is mentioned in passing frequently in the representation in follow-up studies, reviews (comp. sections 3 and 4) as well as in the above-mentioned treatments, results and differential indication examination (comp. section 6.2). In the following, we will highlight especially markedly conditions and attitudes to stimulate the research of their influence in the future.

Attitude towards gender reassignment. It is to be noted first that all authors who participated in follow-up research fundamentally understood that hormonal and surgical treatments are agreement contributions to lower the suffering of patients who live in the discrepancy between physical reality and gender identity. This differentiated them from other specialists who adamantly disapproved of the procedure (comp., for example, some of the discussants to the 66th Meeting of the Southwestern Germany Psychiatrists and Neurologists in Mitscherlich, 1950/51 and Mitscherlich et al., 1950/51a, b). Some considered these procedures very critically and some of them had to overcome strong personal doubts (e.g., Ball, 1981). A sex change seemed, for some, absolutely impossible. They therefore rejected this term as unfitting to describe this treatment (e.g., Benjamin, 1964a; Randell, 1969; Hertoft & Sörensen, 1979; Eicher, 1984). They did not think that the treatment was "the philosopher's stone", but saw in it a pragmatic treatment possibility that they performed sometimes with great scruples and only half-heartedly, of which the surgical procedures of the first two decades illustrated in part 6.2.3 are special testimonies. Some patients who had their testicles only transplanted, not removed, where -- in addition to the uncertainty about the effects of such a procedure -- fear of being punished by law for performing an unauthorized castration and surgical procedures on a bodily-fit human played a significant role. In reviewing the follow-up studies of the first two decades, the unusual interest of many examiners regarding the criminal records of patients is noticeable in comparison to other patient samples. In states in which prostitution, transvestism or homosexual acts were persecuted, it could be understandable to use the frequency of criminal acts as a measurement of changes in the pre- and post-comparison. However, we suppose that the abnormal interest of the examiner regarding the criminal records of patients is due to projective defense. Hastings (1974) suggested to take fingerprints of all patients and have them checked countrywide to determine if they had committed a crime somewhere. Eicher called "the refusal to specifically declare that the physician is not responsible for the consequences of the surgery if it was done according to medical standards" an "exclusion reason" (Eicher, 1984, p 79) and introduced therewith a perimeter in treatment unusual when other medical operations were deemed as medically necessary.

It was the patients who convinced the treatment providers that this form of therapy, regardless of how imperfect, contributed subjectively to the diminishing of their suffering. The defensive attitude of treatment providers was substituted by one more offensive treatment in which the procedure that was sensed as conflicting was united with research interests and thereby took away some of the doubts. Exemplarily this change of mind can be followed in the different publications of Pauly, even though this author -- such as, for example, Hastings (1974) -- would have preferred prevention to treatment if he had found a promising starting point (unpublished discussion remarks of the 10th International Symposium of Gender Dysphoria, July 9-12, 1987 in Amsterdam). From the start of the 1960s the research interests came stronger into the limelight with the first prospective research (Wålinder, 1967). In the form of more or less research organizitorial interest, they formed the Gender Identity Programs in university clinics (e.g., Kando, 1974; Hastings, 1974; Meyer & Reter, 1979; Hunt & Hampson, 1980a, b). It was the greater acceptance of the treatment by this that in some cases there were over-excited visions of the future - such as the one of Edgerton & Meyer (1973), where they presented for the future the transplanting of ovaries and wombs as another possibility for gender reassignment. Statements such as this were very few. Only if one views it very superficially one can read corresponding views in the title of the publication of Kamprad & Gooren (1991). Gooren answered there in the documented discussion Kamprad's question if he, as a medical professional who does gender reassignment, isn't altering God's plans: "A doctor will do this the whole day. He will do it to fulfill the creation" (Kamprad & Gooren, 1991, p 62). By the context it is clear that he did not intend to nourish omnipotent fantasies with sex reassigning surgery, but -- to the contrary -- he wanted to fight them by remarking that gender reassignment, in principle, does not distinguish itself from other medical procedures. This is the attitude that is shown in most follow-up research of the last two decades. The previous fundamental discussion that was done sometimes -- such as in the fight about beliefs if such a treatment is in any way agreeable and approvingly -- was substituted by sober questions with what methods and under which conditions, what could be achieved with whom.

Treatment or research program. To be able to make a differential indication of treatment steps presupposed, if it should be founded, the evaluation of many courses of treatment. Typology and diagnostic classification, homogenizing of partial samples after certain characteristic features and control variation of treatment conditions were unavoidable steps for such research intents. They permitted to isolate effectiveness factors. But they had the inherent danger that individual characteristics did not get their right and they influenced, naturally, the treatment of single patients. In the follow-up studies, the reflection of these influence factors is missing completely.

If the treatment program was thought of as severe and the time until the surgical procedures as waiting time for the patients (Spengler, 1980) or, if to the contrary, the researcher and "the program" were interested and reserved to that what the patients did by themselves (Meyer & Reter, 1979) or if in a project different types of life assistance was given (Gandy, 1973; Laub & Fisk, 1974), it was always conducive to a different type of doctor-patient relationship. Also, if the treatment was in the hands of a single person or very few specialists, or if the patient had to affirm him/herself before an entire team at a gender identity clinic had an influence. With high probability, this had, on the other hand, influences on the accentuation to the claim of being accepted as a member of the other gender.

Finally, the analogy is also true regarding all person-related and social indication criteria that were mentioned in the previous section. If treatment providers support their indication decisions, for example, on the strict differentiation of transsexualism and other forms of sexuality and they think that transsexuals have to be asexual and be against homosexuality, then they will exclude patients from treatment who are different or else patients will simply parrot their opinions to reach their personal goals. Probably this is how it is to be explained that, for example, in follow-up studies in Minnesota (e.g., Kando, 1973; Hastings, 1974; Hastings & Markland, 1978) and Australia (Ball, 1981) homosexual behaviors were not observed and that in other Follow -up studies, the frequency of prostitution differs widely. Stürup (1976) described a male who -- probably due to these reasons -- did not even mention that he was married, which complicated the course of his treatment.

In the clinical works, one could experience in the beginning of the 1980s again and again that patients came with a streamlined transsexual anamnesis to the first interview, oriented by guidance symptoms catalogs (e.g., Sigusch et al., 1979). They seemed to have abandoned all individualism and adapted the expected and sometimes real expectations of the treatment provider. The treatment providers could then only find what they were expecting anyway without pondering that they formed -- by their expectations -- that "reality" that they were seeing. How the facts and symbols in medical case histories and the autobiographies of gender changers intermingled is described by Runte (1992).

The pre-made opinion of treatment providers with most consequences was the negative evaluation of psychiatric and psychotherapeutic influence possibilities. That, with the exception of a widely ignored Finnish research (Alanko & Achté, 1971) determined follow-up study literature until Lothstein's publication (1980). Only after that the rigid alternative surgery vs. psychiatric-psychotherapeutic treatment was loosened and -- at least among some treatment providers -- reached the knowledge that it does not necessarily mean the failure of psychiatric-psychotherapeutic treatment if the patient undergoes surgery after such treatment, nor that surgical treatment is devaluated if a patient can abandon the wish for it during psychiatric-psychotherapeutic treatment (e.g., McCauley & Ehrhardt, 1984). Already Alanko & Achté (1971) deemed it absolutely necessary that a patient had to receive supportive psychotherapy before and after surgical procedures and Lothstein (1980) had discovered that unveiling psychotherapuetic work is frequently only possible in fruitful post-surgical treatments.

Evaluation of treatment results: It is to be supposed that the pre-made opinion of treatment providers and the criteria catalogs valid within treatment programs determine also the evaluation of results and then again have effects on future indication decisions. This is unavoidable and not problematic, as long as the corresponding criteria are reflected upon and are justified. If the gender dysphoria is seen primarily as an identity problem that does not regard sexual behavior immediately and necessarily, such as, for example, Kuiper & Cohen-Kettenis (1988) will ask less questions regarding this in the follow-up studies. Correspondingly Stürup (1976) had considered physical examinations as inappropriate. By starting from other premises, other researchers went much more into detail (e.g., Pomeroy, 1967; McEwan et al., 1976; Blanchard et al., 1987; Ross & Need, 1989) even to test excisions of the vagina (Kröhn et al., 1981).

We deem as important to remind about this factor because in some publications complications and undesired results of treatment are classified as the result of personality disorders or lack of cooperation of patients, even though the transmitted data indicate that also treatment was insufficient. It was differentiated too little, for example, if demands of more (corrective) surgery was prompted by non-satisfactory primary surgical results or what surely happened in some cases - an expression of poly-surgical wishes in the sense of a Münchhausen syndrome (e.g., König et al., 1971; Sörensen, 1981a; comp. to Lothstein, 1980). Regarding the relatively frequently common complication, vaginal stenosis, many times the lacking cooperation of the patient has been lamented about and it is seldom said that even frequent treatment can not correct a corresponding unsatisfactory surgical result (comp. Lindemalm et al., 1986; Blanchard et al., 1987; Stein et al., 1990).

As already shown in the sections about suicidal tendencies and role-rereversal (comp. Sect. 6.2.6), the authors tend to presuppose, in suicide attempts and suicide previous to starting treatment, a connection with the transsexual symptoms and tried to find, in post-surgical suicidal tendencies and role reversal, mainly reasons that did not have any relation with treatment.