Alanko & Achté, 1971
Psychiatric University Clinic, Helsinki, Finland

This is the first follow-up study of transsexuals published in Finland. The authors called it a provisional report. In reality it remains the only Finnish publication regarding this theme (according to a personal note from K.A. Achté to F.P. on November 13, 1989). It is not quoted by most authors of later follow-up studies.

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

Study Methods
The study methods and instruments are not named.

Evaluation Fields and Criteria
The results of the treatment are divided in the relation of the pre-surgical findings in the categories "better," "same," and "worse". Results were evaluated as questionable if the surgery happened less than six months earlier.

Case Studies
All courses are described extensively. We take over the symbolizing of patients with letters in the publication.

Females: The patient #5 was only operated one month before the follow-up study and was classified as content. The patient #2 had lived for 15 years in the USA and had met Harry Benjamin there, who started her hormone treatment. In Finland an application for castration was first denied but, despite this, sex reassignment surgery was done. For a follow-up study this female was not available. The patient #7 is classified as worsened because she was very depressed and unhappy with the surgical results. She was operated on without pre-surgical hormone treatment. Patient #8 is described as content. Her follow-up study period was six months. Patient #1 -- who at age 28 had a castration -- is called "homosexual" by the authors. Two years later a penectomy was done and a vagina was made, even though the patient had never lived as a female before. Post-surgically he/she lived one year as a female and lived with the parents. The authors characterize him/her as paranoid, but not psychotic. At the time of the follow-up study, ten years after surgery, he was living again as a male. He said that now he understood better why he previously desired a sex reassignment. The authors evaluated his well being at that time compared to the start of treatment as unchanged.

Males: The situation of patient #3, whose surgery (including phalloplasty) went back five years, was evaluated as being better, even though it is said at the same time "A thorough psychiatric follow-up investigation has not yet been carried out" (p. 355). Patient #4 is classified after a three-year follow-up study time as better. Patient #6 is described as content, even though the surgery had been performed only one month earlier.

Results
The results are represented in the form of case studies. Overall, of the four females one each is evaluated as better, questionably better, equal, resp., worsened. Of the three males two were evaluated as better and one as questionably better.

Suicide Attempts/Role Re-reversal
The authors estimate the suicide risk of transsexual patients as, overall, very high. Regarding the patient #1, they speak about a reversal into the previous male role with the same shape as pre-surgically, not about a so-called re-reversal desire. There are no reports about an explicit wish to reverse the surgical steps.

Follow-up Studies Mentioned
Benjamin, 1964b, 1966; Hamburger et al., 1953; Pauly, 1965; Randell, 1969; Wålinder, 1967.

Authors' Conclusion
The authors highlight that it is important to note that surgical treatment as well as hormonal treatment are only mosaic pieces of an intensive and long-term psychiatric treatment of transsexual patients. Therapeutic success cannot be achieved alone by surgeries. They compare the state of the treatment procedures for transsexuals to the lobotomy at the time when it was introduced as psychiatric treatment. "Apart from psychiatric and hormonal therapies, the sex transformation operation is, for the present, the only means at our disposal through which we can help in certain severe cases a human being suffering from a very grave disorder" (pp. 352).

Indication Recommendations
With emphasis the authors warn to use special care with the extension of indication, for which they presuppose a two-year-long psychiatric complimentary treatment, if possible, one to two years of psychotherapy, two years living successfully in the other gender role, a stable personality and that "the diagnosis is correct beyond doubt" (p. 352). Psychoses and borderline personality disorders should be excluded and mainly the continuous follow-up treatment and continuing of supportive psychotherapy should be guaranteed for years.

Remarks
The extensive case studies show how big the insecurity of medical doctors was when being confronted with patients with transsexual symptoms. Also in the diagnosis as well as regarding the indication for the different therapeutic measures, there seemed to be no uniform concept: On one side, a patient was (at first) denied the surgery despite a many-year-long hormonal treatment (patient #2) . On another side, a patient (#1) was operated without any previous hormonal treatment.