Walser, 1968
Psychiatric University Clinic, Zurich, Switzerland

The intent of the author was to work out, by means of long-term katamnestic observation, criteria for the therapeutic procedure. Compared to many later follow-up studies, these are, on the average, very long katamnesis time periods. The selection of the suitable treatment steps and the prognosis depended mostly on the personality structure of the patient in the author's impression. The author developed a typology oriented on the personality structure and course that contained the sub-group (1) accidental transvestites, (2) personalities heavily disturbed psychopathically; (3) weak and not very assertive personalities, (4) vital but unstable personalities and (5) mostly vital, over average intelligence and stable personalities. For the latter, he though that the prognosis would be overall favorable.

• Sample
• Study Methods
• Evaluation Fields and Criteria
• Results
• Case Studies
• Role Re-reversal
• Follow-up Studies Mentioned
• Authors' Conclusion
• Remarks

Study Methods
Ten patients were examined by the author. For three patients who had already deceased for the evaluation the hospital file was used and relatives and friends of previous patients were questioned. Four patients could not be reached because they were abroad. The evaluation was based in these cases also on the evaluation of previous hospital files and correspondence. "With our 17 patients we had 86 objective sources at our disposal. These were: information from relatives and friends, medical files (also about times in hospitals for somatic illnesses), files of authorities and courts of law, medical expertise, information and written reports from treating physicians. For each patient we used an average of five objective sources" (p. 420). About the circumstances, time period, content of the research and methodology as well as the research of other sources are not mentioned.

Evaluation Fields and Criteria
Evaluated and compared were the personal data and marital status, profession, capability to work and psychiatric personality evaluation at the beginning, during and at the end of the observation period. Indications of hypogonandism, magnitude of sexual drive and sexual orientation were noted. The start and the course of transvestite, resp., transsexual behavior were annotated in noted form.

Results
Legal name and sex change: For seven patients, the sex entered in the civil registry was changed by a court. Between the time of application and the carrying out, a mean time of eight years had passed (range: 3-18 year). In one case each, with an Austrian, resp., an Italian national, the legal sex change was done many years before corresponding laws existed.

"Six of our 11 operated transsexuals show a social improvement (comp. Professional Position and Capability to Work). Three lost social status" (p. 423). "Two patients lost their social position after they became paranoid. One developed an impeding mania and the other lived through a paranoid schizophrenia." (p. 424).

Regarding the pre- and post-surgical evaluation of the personality(table, p. 419) the before-mentioned patient with the impeding mania had suffered a notable worsening. All others were mostly unchanged or an improvement was registered.

"None of the operated formerly physically male transsexuals has had sexual relationships after surgery. Some of them were very sexually active before surgery. This giving up can be due, in part, to not feeling as completely sexually able following surgery, which corresponds to general experience with operated transsexuals." (p. 424).

The previous paragraph is negated by the table (p. 420), according to which the magnitude of the sexual drive is described as normal for six, for three as strong and in three as hypo or asexual.

Case Studies
For all 17 patients included in the follow-up study, the most important data is annotated in table 4. Five prototypes for the course forms mentioned at the beginning are described to a larger extent

Role Re-reversal
One MFT who had only had a castration and had lived some years as a female lived later as a male. He was bitter because more surgery had not been made available to him. One MFT who could not get through the legal sex change at the end of the research lived, despite hormone treatments and surgery, as a male and wanted to make the change only when he was legally recognized as a female.

Follow-up Studies Mentioned
Benjamin, 1964a, 1966

Authors' Conclusion
"The case number is too small to allow clear conclusions ... the healthier, more gifted and more active the personality -- disregarding the perversion of transvestism -- and the more the desire for 'sex change' is mentioned permanently, the more favorable the prognosis." (p. 430). According to this, all patients of group five had a favorable course. "None of the patients of this group showed an addicted personality." (p. 430). As the cases of group four show, " ... the post-surgical course with the patients with at first seemingly doubtful prognoses is much more favorable than the pre-surgical, insofar as the indication is done right." (p. 432). "Therein the personality structure of the patient seems to be of a special prognostic importance. " (p. 433). "In our research material of 11 males and six females, the relation with males of favorable to unfavorable is 6:5 and with females 5:1. The course with females is much more favorable." (p. 433; note: the author uses the gender identification in the traditional sense.).

Remarks
This notable -- and in the follow-up study literature, almost not reported publication -- is not always consistent in its numerical statements. Disregarding this, is is notable because it documents long-term courses and formulates differential diagnostic thoughts, even though these are trivial in their results (structurally more healthy patients can cope with a sex change better than those who are sicker). It is noted how important, besides the psychiatric and somatic treatments, the judicial side of the legal sex change is for the rehabilitation of the patients. The author rightly denies the prejudice that was expressed in those times in Switzerland, according to which every transsexual, in the frame of the legal sex change, was to be put under patronage and declared post-surgically as being unable to enter marriage. It is remarked for the patients described in group five (five males, one female) that treatment was finished successfully and that no addictive developments were noted. Sadly, as in most follow-up studies, one learns little about the type of long-term psychiatric treatment. It is notable that at least one patient had hormonal and surgical treatment steps even though the patient lived in the original role and without previous legal recognition; the patient did not want to make a change.