Spengler, 1980
Dept. of Sex Research, Psychiatric Clinic, University Hospital Eppendorf, Hamburg, Federal Republic of Germany

This follow-up study was done in the frame of the consultation for a transsexual law -- in a rather fast fashion -- to highlight the importance of a legal recognition of the gender reassignment.

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

Study Methods
The author, who did not participate in the treatment indication, conducted semi-structured interviews with patients for a half hour to one hour. Data for the pre-surgical situation was taken from clinic files.

Evaluation Fields and Criteria
The following areas were included for the evaluation of the post-surgical situation: employment; social relations; sexual behavior; emotional adaptation and corrective surgery desires. The author thought that this data was mostly independent of the researcher.

Results
Females: In the treatment periods four females lost their employment. Before surgery four changed professions, after surgery five. Before treatment one female was unemployed; after treatment two females were unemployed. The formal acceptance of the role at the work place was unsure for five females pre-surgically but post-surgically was accepted for all. Contacts to the family existed pre-surgically for eight and post-surgically for nine females. While pre-surgically only seven of the 13 females had contacts to acquaintances, friends and colleagues, this was true for all but one post-surgically. Six females lived in on-going partnerships after surgery. Eight had attempted sexual intercourse which was possible for two with difficulty and for another two was not possible at all. Eight females reported about orgasms in connection with sexual intercourse or other sexual activities. The fact that they had been operated was evaluated by six females each as very positive, resp., positive. One female whose treatment was not finished was insecure about it. Depressive mood swings were experienced by two females who had finished treatment and by three whose surgical treatment had not yet been completed. Disregarding the mood swings, almost all females reported they felt better since surgery. Further corrective surgery wishes were mentioned by four females whose surgeries were not yet finished and six females for whom treatment was considered completed. Five females desired surgical breast enlargement.
Males: In the treatment time period three males lost their employment. The formal acceptance of the role at the workplace was a given, pre-surgically as well as post-surgically for three patients; for two it was unsure. One male was not accepted in his workplace pre-surgically; one male was unemployed post-surgically.
All males had contact to their families as well as social contacts to friends, acquaintances and colleagues pre- and post-surgically. Five males lived in continuous partnerships. Emotionally, all five felt stable and evaluated the fact that they had been operated as positive, resp., as very positive. Only two, whose surgical treatments were not yet finished, reported about depressive moods. Further surgical correction wishes regarding a phalloplasty were expressed by two males.

Suicide Attempts
Out of previous records from five of the 19 operated patients, suicide attempts were known. Another not-yet-operated patient had committed suicide. Post-surgically three females who had previously attempted suicide expressed suicidal thoughts, but did not make any new attempts.

Follow-up Studies Mentioned
Hastings, 1974; Hastings & Markland, 1978; Jayaram et al., 1978; Money, 1971; Money & Ehrhardt, 1970; Steiner, 1976; Wålinder, 1967

Authors' Conclusion
"The binding severe rules in existence since 1973 for the indication of a waiting period of a 'Real-Life-Test' and pre-surgical treatment with hormones generally have a justification. A very regimented treatment program is absolutely necessary. Especially for patients who have been treated with hormones somewhere else, a longer observation period is necessary. Under these conditions, it is to be observed in our patients -- with few exceptions -- a good post-surgical stabilization despite the encumbrance by external factors and of the not completely classic transsexual anamnesis" (p. 102).
The author calls the surgical interventions "in view of the failure and in lieu of therapeutic alternatives, a treatment which we are forced to offer. As such, it is a necessary cure and saves many patients from an unbearable life, as such it has demonstrated success" (p. 103).

Indication Recommendations
"For the indication for male-to-female patients unfavorable prognostic constellations seem to be: poor social integration, for example, bonding to the transvestite sub-culture; poor history of friendships and partnerships; separation from the family; low education; a hormone treatment not indicated by us and therefore a prevention of a planned therapeutic polarization towards the surgery; bad cooperation on the part of the patient; an unclear treatment plan; poor counseling; long-year development of transsexualism and years of fighting off this orientation, for example, by attempting to marry, and tendencies to suicide and self-mutilation" (p. 102).

Remarks
Short and long-term katamnesis are excluded arbitrarily from the research with the argument that "emotional and social reactions change strongly over a longer time" (p. 98). Especially if this is true, data based on long-term katamnesis that was available to the author would have been more conclusive. The factors classified as prognostically unfavorable cannot be deduced from the data of the author, even if they were adequate. The severe treatment regime requested by the author does not really show what is offered to the patient as help or could be offered - except the severity. Also, the frequently repeated statement in literature of the failure of psychotherapy cannot be proven in this -- or comparable follow-up studies -- especially because here the pre-surgical treatment was mainly named as the giving of hormones and a "Real-Life-Test" characterized as a mere "waiting period".