Wålinder & Thuwe, 1975
Psychiatric Research Center, St. Jörgens's Hospital, University of Göteborg, Sweden

This unusually thorough follow-up study picks up the thread of a previous publication of Wålinder (1967) where -- for the first time in Scandinavia -- a large sample of transsexuals was presented extensively under clinical viewpoints. It documents the further courses of treatment of patients described and contains many important details for the clinical physician who cannot be repeated here in this short summary.

• 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 authors who participated in indication and treatment had one to two hour interviews with the patients, with partially open and partially given questions with fixed answer categories. Further, the Swedish Social Security Register and Register of the Governmental Health Insurance (in which all Swedes must be registered) was viewed.

Evaluation Fields and Criteria
Besides the criteria used by Money & Ehrhardt (1970), namely the length of partnerships, employment, criminal records, mental condition and subjective evaluation of the surgical results, the authors asked about sexual behavior, living conditions and relationships with relatives. The Swedish Social Security Register supplied data about alcohol abuse, criminal records and need for social welfare and out of the Register of the Governmental Health Insurance data about illnesses and medical retirements. Special evaluation scales were defined as (pp. 12-13) and include the following topics which we summarize:

Results
Females: All females felt erotically attracted to males, as had been the case before treatment. Four females had a libido increase and two a decrease. Overall the post-surgical sexual adaptation was very good for two females, for five satisfactory and bad for four females. While pre-surgically none of the females were married post-surgically seven entered marriage, of whom two were divorced again. Eleven of the 13 females had severe mental problems before treatment; post-surgically five females were evaluated as bettered, one as worsened, two as unchanged-good and three as unchanged-bad. Employment situation: It was unsatisfactory pre-surgically for six females, for seven satisfactory. Post-surgically it was excellent for one female, satisfactory for seven and unsatisfactory for only four females. The living conditions were bad for five females and for eight satisfactory pre-surgically, while post-surgically it was bad for only one female, for ten satisfactory and for two even excellent. The conditions in this sector had improved for six females. Additional to the four females who before surgery already received social welfare post-surgically two others received this type of support. The alcohol abuse of two females was unchanged by the treatment. Pre-surgically two females had criminal convictions and post-surgically, one. During the treatment no female received a medical retirement, but post-surgically three females had such a retirement, mostly because of psychiatric reasons. The relation to relatives and their attitudes toward the patients did not worsen in any cases, but improved in four cases.
Two females saw the treatment as unsuccessful and regretted their decision. Five females evaluated the result as good, even though they still had to fight with some psycho-social problems. Satisfied without limitations were five females.
The researchers evaluated one case as unsuccessful and another one as hardly satisfactory, four as satisfactory and five as very satisfactory. The appearance was evaluated for two females as relating badly to the new gender role, for four females as satisfactory and for five as very good.
Males: All males felt erotically attracted to females, as had been the case before treatment. For three men, the libido increased and for one it decreased. Overall the post-surgical sexual adaptation for three males was very good, for five satisfactory and for three males bad. Pre-surgically three males were married and post-surgically nine were married - of whom one -- at the time of the follow-up study -- was divorced again. Nine of the 11 males had pre-surgically severe mental problems. Post-surgically eight males were evaluated as mentally improved, two as unchanged-good and one as unchanged-bad. The employment situation was unsatisfactory for four males and excellent for one before surgery. After surgery only two males were classified in this areas as unsatisfactory, while three were satisfactory and six were excellent. The living conditions was pre-surgically bad for four males, for seven satisfactory. Post-surgically six males had improved so that the living conditions of nine were satisfactory and two excellent. The social welfare (four males), alcohol abuse (two males) and criminal convictions (two males) had no noticed change. Medical disability retirement was not received by any male. The relationship with relatives and their attitudes towards patients did not worsen in any case.
Subjective was none of the males so unsatisfied with the results that he would have regretted the treatment. One male got along relatively badly in the new situation and had to continue fighting severe psycho-social problems. Three males evaluated the results as good and seven were satisfied with every aspect of the treatment.

Case Studies
More than half of the publication (40 of 72 pages) is dedicated to the explicit representation of all patients' histories that are divided into history, first contact, treatment, follow-up treatment and representation of results.

Suicide Attempts/Role Re-reversal
Pre-surgically six of the MTFs had attempted suicide once or more. Among these are also those two who were not available for the follow-up study. Post-surgically three suicide attempts were documented for females. Two of the three females belonged to those six who had attempted to take their lives pre-surgically. One female died two years after surgery because of a sleeping pill overdose. She had many surgical complications but appeared to the researchers in previous examination dates to be balanced and not depressed. The authors do not see an immediate connection between the sex reassignment and the suicide of this patient. Two females were evaluated as unsuccessful and regretted having made the gender reassignment. The explicit case representation (pp. 33-37) showed that this regret was not connected to a desire to re-revert roles.
Of the FMTs three had attempted suicide pre-surgically. One of these three males attempted suicide again after surgery.

Follow-up Studies Mentioned
Benjamin, 1966; Hoenig et al., 1970a, b, 1971; Money & Ehrhardt, 1970; Pauly, 1968, 1974; Randell, 1969

Authors' Conclusion
The authors think that a follow-up study time of at least three years since name change, resp., surgery, as sufficient to evaluate long-term results that are not influenced by the immediately post-surgically observed alleviation effect. A major part of the difficulties experienced post-surgically by transsexuals they attributed to shortcomings of the psychiatric-psychotherapeutic and mostly the surgical treatment. They think that their sample is too small to make big statistical analyses so that they cannot work out the reasons to attribute treatment successes. "The result of our follow-up study has been rather more positive then we had dared to hope... When we consider the severe suffering and the many difficulties experienced by untreated transsexuals in various spheres of life, the treatment programme appears to be fully justified, both medically and ethically" (p. 31)

Indication Recommendations
As risk factors and relative contra-indications against hormonal and surgical treatment the authors mention:

Remarks
This research is exemplary with its exact and explicit katamnestic statements for each patient, the operationalyzing of evaluation criteria and the evaluating discussion of findings. Especially in the case studies it is notable how the post-surgical findings were put in relation to the pre-surgical initial data. Improvement or worsening of the situation of patients are described to such an extent that the evaluation of the authors can be followed; it is also discussed in how far the described changes are in relation to the treatment or whether to be seen independently from it.