Hoenig, Kenna & Youd, 1971
Dept. of Psychiatry, Memorial University of Newfoundland, St. Johns, Newfoundland, Canada and Manchester Royal Infirmary, Dept. of Psychiatry, University of Manchester, Manchester, Great Britain

This is an interdisciplinary (psychiatrist, clinical psychologist, psychiatric social worker) Canadian-British (both co-authors worked in Manchester) joint publication, wherein the detailed diagnostic treatment and results for patients of Manchester (UK) are represented. The sample describes a partial sample of operated patients of bigger treatment collectives of the authors (Hoenig et al., 1970a, b). The first of those publications (1970a) reports about sociographic and psychiatric data of 60 patients who have visited ten years previous to the publication the Psychiatric University Clinic in Manchester and were diagnosed, supposedly without a doubt, as transsexuals. (Doubts regarding this figure are in order because 25% of the patients were only between 15-19 years old and 13% were manifestly psychotic.) The second publication of the same year (1970b) describes the same sample as a follow-up study, but only under the viewpoints of the influence that the name change had for the work anamnesis, dependency on social welfare, criminal convictions, prostitution, partnership and so on. Because the study 1970b does not differentiate sufficiently between operated and non-operated and because the corresponding data is only repeated in the here referred to follow-up study (1971) for the partial sample of operated, we only report about the last one.

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

Study Methods
The research methods are not specified. Probably they included physical examination and clinical interviews of a partial sample taken from previous publications (com. Hoenig et al., 1970a, b). Examiner and patient evaluation sometimes converged. The authors participated in the treatment. MMPI and IQ (Wechsler-Bellevue) were used as psychometric methods.

Evaluation Fields and Criteria
As pre-surgical situation only data about the professional situation, psycho-social adaptation, familial background, prostitution and criminal conduct are made. The post-surgical situation is described by data about hormonal treatment, continuity of professional activity, financial independence, attitude of the family, sexual activity, promiscuity, prostitution and criminal convictions.

Results
Females: Only one female was continuously employed. Three had only temporary work and were at least for some time dependent on financial support. One female, who was a homemaker, received welfare. None of the females worked as prostitutes. Promiscuity is negated for two females, affirmed for one and one was less promiscuous than before surgery. For one female there is no data. One female had a criminal conviction after surgery. Four patients had been convicted of "sex crimes" before surgery and some where incarcerated for years. They were accused of homosexual acts and transvestism.

Measured by fantasies, not behavior, all females except one were placed in categories V-VI of the Kinsey et al. Heterosexual Homosexual Evaluation Scale. MMPI, N Scale 9-34; E Scale 4-32; IQ Wechsler-Bellevue (95-130). Four of five had psychiatric additional diagnoses, mainly sensitive personality disorder, depression, attention-seeking personality disorder, insecure personality disorder and alcoholism problems.

The global evaluation of patients and authors are: Patient #5: subjective: "much happier after 1st operation, but disappointed in 2nd"; authors: "perfectionist drive leading to disappointment with result of operation". Patient #6: subjective: "very satisfied; hoping for vaginoplasty without undue anxiety"; authors: "satisfactory outcome; patient seems generally happier". Patient #7: subjective: "very happy about 1st operation, married after 2nd operation"; authors: "sexually less promiscuous, work record more stable". Patient #8: subjective: "adapting well, enjoying role of housewife"; authors: "wanting nose operation; also further vaginoplasty, drab suburban housewife" . (Because the patient previously never had said that she found her nose too big, it was the opinion of the authors that one is forced to think that she has a Münchhausen Syndrome.) Patient #9: subjective: (Leukotomized patient). "no benefit"; authors: "none the worse for operation, but has not helped transsexualism" (p. 117).

Males: All males were employed after surgery and independent of financial support. None of them behaved promiscuously, worked as a prostitute or had criminal convictions.

Measured by their fantasies and not their behavior, all the patients were classified in the Kinsey e. Al.Heterosexual Homosexual Evaluation Scale in the category VI. MMPI, M Scale 1, 32, 8; E Scale 18, 26, 35; IQ (Wechsler-Bellevue) 124, 88, 115. One male had an additional psychiatric diagnosis, "labile personality disorder."

Subjective: All males were very satisfied, resp., very unburdened, by the treatment. Contrary to this, the authors evaluated one patient as being latent suicidal because of his disappointment that the phalloplasty had not been done and for another one they evaluated the cosmetic results of the surgery as being unsatisfactory.

Case Studies
For all patients the anamnesis, treatment and post-surgical course is reflected.

Suicide Attempts/Role Re-reversal
Two MFTs had attempted suicide before surgery, one of them after being sentenced to prison for homosexual acts. The other one had three severe suicide attempts, which were every time he was told that he could never achieve his goal of sex reassignment. Post-surgically one female threatened suicide after multiple unsuccessful vaginal surgeries without making any attempts. For one male, who was very disappointed that he did not receive a phalloplasty and who avoided contact to the clinic more and more, the authors decided that he was sometimes latent suicidal.

Follow-up Studies Mentioned
Benjamin, 1966, 1967; Hamburger et al., 1953; Hertz et al., 1961; Hoenig et al., 1970a; Pauly, 1965, 1968.

Authors' Conclusion
The authors called their sample small and the follow-up study period short. Despite these limitations, they declared the results of their research was that the treatment helps subjectively and objectively the majority of the patients and is "definitely satisfactory" (p. 120). Of nine Followed up patients, seven got along well. The differentiation normally used in the literature of satisfactory and unsatisfactory results was not distinct enough for the authors and was not deemed as adequate because it "conceals the immense complexities which constitute the individual existence of a transsexualist, of his >> being in the world<<" (p. 121).

Hormonal treatments and surgical procedures are, in the estimation of the authors, non-healing in the normal sense because they do not change anything about the syndrome. They only help for a better adaptation and bigger tranquillity provided they are part of a broader approach to which a patient is helped to adapt within and without. As to the single aspects, the authors declared that the leucotomy is not adequate for the treatment of transsexuals and that the hysterectomy and orchidectomy should be replaced by the gentler (sic!) X-ray castration.

Indication Recommendations
Patients with marked personality disorders should not -- or only after a long previous observation phase -- be operated. The social environment of the patient should be considered because patients without support of family or friends and a social net have a worse prognosis. Alcoholics and drug addicts, mentally impaired, schizophrenics and patients who suffer from affective psychosis should be excluded from the surgical treatments. Perfectionists are seen by the authors as problematic candidates because they can, under certain circumstances, take a poor surgical result badly. The authors admit that a contra-indication must be carefully weighed against the risk of suicide or self-mutilation.

Remarks
This explicit publication treats a multitude of single aspects, all of which we could not refer to here. Despite much detailed information, for example, about the time of the previous treatment, time interval between the first surgical intervention and later surgery, many references are contradictory (e.g., follow-up study period of patient 5) or cause confusion rather than clarify. The latter is especially valid for sample descriptions. While the postal address of the first author as well as the unclear references in the publications of the same authors (1970 a, b) let one at first suppose that they are three works of two different samples - namely a Canadian and a British, in all three publications the same patients in Manchester are described.

Like in many publications about transsexualism, moral values, partially hidden under psychiatric terminology, take lots of space. The existence, resp., the non-existence, of a not-qualified promiscuity or prostitution, are a measurement for treatment success. If patients say that they are disappointed about evidently bad surgical results and demand more surgery, then this is evaluated as "a fairly severe personality disorder with strong perfectionistic traits" (p. 118) or even if a patient desires a corrective nose surgery, it is evaluated as Münchhausen Syndrome. Possible shortcomings of the treatment are not discussed in this relation. The authors are critical about the leucotomy as treatment for transsexual symptoms, yet, on the other hand, they seem uncritical about X-ray castration.

At the start the authors mentioned literature that is critical of gender reassignment surgery (Mitscherlich, 1950; Ostow, 1953; Wiedemann, 1953; Gutheil, 1954; Meerlow, 1967) without debating their arguments. Placatively it is said that anyone who denies sex reassignment because of moral or ethical thoughts should not be interested in follow-up studies. The authors argue that from a therapeutic viewpoint, these are indispensable.