Stürup, 1976
Psychopath Institution Randers, Randers, Denmark

The author had made the indication for the first, and at the same time notorious, gender reassignment surgery of George/Christine Jorgensen in 1951 in Denmark (Hamburger et al., 1953) and participated in the 1950s and 1960s in the treatment and surgery indication for almost all transsexuals in Denmark. He felt compulsed by Stoller's (1972, p. 306) remark that surgical treatment of transsexuals was dangerous to present a long-term follow-up study. He called it a scandal that 20 years after the first surgery, no corresponding research about long-term effects existed.

• 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 author who participated in the indication and treatment conducted unstructured interviews or corresponded with the females, their partners or family members.

Evaluation Fields and Criteria
The author did not think that schematic methods were appropriate for the follow-up study. This is why he did not systematize what areas were to be talked about in the interviews. Usually he asked about the history, subjective satisfaction, suicidal tendencies, partnerships/marriages, professional and familial situation as well as sexual experiences. A physical examination or an inspection of the surgical results were not considered adequate by him.

Results
The results are described in case studies. Overall it is said that all ten females were satisfied or very satisfied with the results.

Case Studies
The author has divided them into three groups. He included six females in the first group typical transsexuals. They distinguished themselves in that they had led a mostly asexual life before surgery and had mostly (n=4) already in childhood or (n=2) starting in puberty manifested gender identity conflicts. All were satisfied with the operation, independent if they had only castration and penectomy or if a vagina was built and independent if they had sexual intercourse and reached orgasms by it or not.
The second group the atypical transsexuals included three females. They were noted by the "massive sexual activity of a prostitution-like type" (p. 57) in the pre-surgical life also in some of the post-surgical life. The panel who had to authorize the operation had difficulties with these patients. The request of one patient was denied twice (1962, 1966) and authorized only in 1970. Also the second patient of this group waited eight years before her desires were met. Two females did not have orgasms during sexual intercourse. The third, who was happily married, did not have a vaginoplasty.
The third group is formed by a single patient whom the author describes as complicated type. This male had kept his marriage a secret. After multiple self-castration attempts and unsuccessful treatment with male sexual hormones, finally a treatment with female hormones was started and later a castration was done. After a multiple-year life in the female role (without a name change because he was still married) the patient lived 19 years after the surgery as a male but was convinced that the surgery was right and only regretted that it happened so late.
The last patient was not operated and only at age 41 was he started on a hormone treatment. After that he abandoned the wish for surgery. After a passing tranquillization he developed a paranoid psychosis, during which he committed suicide at age 49.

Suicide Attempts/Role Re-reversal
For more than one patient there are reports about pre-surgical suicide attempts and auto-castration attempts. Post-surgically due to severe partnership conflicts, two suicide attempts by two females were known. One patient lived post-surgically again as a male without regretting the surgery. Another patient, who suffered a paranoid psychosis, committed suicide. He had previously abandoned the wish for surgery and was not operated.

Follow-up Studies Mentioned
Hamburger et al., 1953; Kando, 1973

Authors' Conclusion
"The main result of the follow-up is that the practical approach to the psychiatric, surgical and social assistance to transsexual persons who have a clear subjective feeling of belonging to the opposite sex, which was developed in 1952 and is now known as sex-reassignment, seems generally to have given satisfactory results" (p. 62) "Now it can be stated that the more harsh, aggressive attacks against the procedure were not reasonable, and the severe predictions (Ostow [1953]) concerning the future of our patient have not materialized" (p. 52).

Indication Recommendations
Patients who are accepted for surgery should be mentally stable. Previous marriages and great sexual activity are not contra-indications, but the patient should be divorced prior to surgery. Even at an advanced age, the treatment can help patients very much.

Remarks
The follow-up study is methodologically at the same level as clinical vignettes. Therein is its weakness because there is little comparable, resp., objectivizable data obtained by these examples. On the other side, its strength is how it shows with how much hesitation in the 1950s the indication for somatic procedures was made and how dychotomically the proceedings were done. The follow-up study is worth reading less because of "objective" data than because of the latter aspect. Self-critically the author remarks that between the indication for castration surgery -- that according to Danish law according to the rules of castration law of the year 1953 must be requested and approved by the Minister of Justice -- and the vaginal surgery, many doctors waited much too long and prolonged the suffering of patients unnecessarily. He responds to Stoller (1972) that it is dangerous if patients are helped only half-way. Also, hesitation of physicians to make a treatment indication for sexually active transsexuals is considered by him as wrong.
It is noticeable in the case studies how much the author respects if his previous patients do not want to talk about their previous situation or to be reminded of it for a follow-up study from which they cannot expect anything positive. To counter Stoller's (1972, p. 306) not totally unjustified demand for elaborate pre and post measurements, Stürup declares in short that instruments for this were not at his disposal (p. 53). One gains the impression that behind this declaration he is hiding the opinion that uncommon biographical occurrences such as sex reassignment will never be measurable with such instruments, but demand an individual representation.