Final Remarks

At the end of this overview about follow-up studies of patients with transsexual symptoms who have been subjected to genital changing and live contrary to their original gender order, one can summarize the results using gross simplification as follows:
In over 80 qualitatively different case studies and reviews from 12 countries, it has been demonstrated during the last 30 years that the treatment that includes the whole process of gender reassignment is effective. Accordingly, all follow-up studies mostly found the desired effects. The most important effect in the patients' opinion was the lessening of suffering with the added increase of subjective satisfaction. Besides this, we found most of the desired changes in the areas of partnership and sexual experience, mental stability and socio-economic functioning level. As an

average , the desired changes were slightly better in males than females and, depending on the starting situation, were more or less markedly in different areas.

In many publications it was reported about complications and undesired effects. Especially in the early years of the reporting time there were frequent and sometimes severe complications in the surgical procedure that in many cases, but not as a rule, could be fixed by corrective surgery. By comparison, the information contents regarding complications of the psychiatric and hormonal treatment were less. Regarding suicidal tendencies, it can be determined that suicide attempts were above average before and at the start of treatment, but that the frequency decreased in a statistically significant manner during and following treatment. Suicides were very rare. Insofar as motives are known, the least of them were in any immediate relation to the gender reassignment. Desires for role-rereversal are the extreme exception. The few that are described in follow-up study literature can be based on the extreme treatment shortcomings.

In the analysis of the treatment effectiveness, seven factors could be demonstrated that markedly influence the results of the treatment; namely, ( 1) continuing contact with a research program/treatment facility; (2) living in the other gender role (Real-Life-Test); (3) hormone treatment; (4) counseling, psychiatric and/or psychotherapeutic treatment; (5) surgical sex reassigning procedures and (6) their quality and finally, (7) the legal recognition of the gender change by name and legal sex change.

Prognostically favorable and, as such, important factors for the differential indication decision were searched for by the authors of follow-up studies primarily in the constitutional and mental properties of the patients. It can be said in a simplified manner that primarily stable and/or psychopathological inconspicuous personalities were classified better in the follow-up studies than primarily instable or psychopathologically conspicuous. Roughly this is analogously true regarding the second factor, namely, social properties of the patient; but there are major differences among the authors in regard to which forms of social properties to evaluate as being favorable or unfavorable. It was hardly reflected in the follow-up studies about the third factor, which we called the treatment-specific factor. It regards structural questions of the treatment setting and especially the attitudes, judgments and positions of treatment providers that define the contacts to patients and have a decisive influence on who is to be treated and how it happens.

If one deems it necessary to make more follow-up study research, then its focus should be on treatment-specific factors. We think that under prognostic viewpoints it is pointedly formulated just as important -- if not more important -- than the constitutional, mental and social properties of the patient.

The treatment-specific factor is the interface where the clinical and sociological perspectives are presently more closely in contact. Here the ways are set how gender reassignment will be in the future. There are many forms thinkable for it, even those in which the change of the anatomic gender characteristics is not as important as in the "historic project transsexualism" as described by Hirschauer (1992 a, b). This is already being done by a big number of people who go with transsexual wishes to treatment facilities but do not complete the treatment offered there. We think it is desirable to have an amplification of the spectrum of possible lifestyles, a wider recognition of unusual lifestyles and a facilitation of different forms of gender change. Even then, the clinical perspective will be irreplaceable. The expectation that, by social changes alone, this form of gender change that we describe under the name sex reassignment will be superfluous, is not shared by us.