Kröhn, Bertermann, Wand & Wille, 1981
Sexual Medical Research and Counseling Center, Urology Clinic, Christian-Albrecht-University, Kiel, Germany

Important in this research is that, to the contrary of many other follow-up studies, in this one it is crystalized how big a role sexuality plays in the experience of the patients, even though it may not be pre-surgically it is so post-surgically, and that a large portion of the patients have homosexual contacts post-surgically. Also amply explained is the limitation (not recommendable phalloplasty) painfully experienced by males of the reassignment.

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

Study Methods
The katamnestic research included an extensive semi-structured interview, psychological test research (Freiburg Personality Inventory, Gießen Test and others not mentioned by name) and the registering of the somatic status - especially the gynecological-urological local findings.

Evaluation Fields and Criteria
Of the patients and of the treatment team, the results were evaluated on three-step scales for the following areas: somatic findings; sexuality; socio-economic situation and emotional course.

Results
Globally, and not separated by gender, it is reported about the results of the comparison of pre- and post-surgical tests (Freiburg Personality Inventory, Gießen Test). Pre-surgically more severe depression was dominant, reduced ability to make contact and negative resonance compared to the corresponding post-surgical test results - that are not shared. All other results are presented separated by gender.
Females: "At the time of follow-up the artificial vagina was totally granulated; there was a recto-vaginal fistula and in three cases the vagina was considerably shortened, but it was only for one patient an absolute co-habitation impediment" (p. 27). For an unspecified number of patients there was an unfavorable immission angle. One patient had a urethral stenosis with dysuric difficulties. Overall, 11 patients evaluated the somatic results as good (researchers' evaluation: eight); five as satisfactory (researchers' evaluation: five) and two as poor (researchers: five). Fourteen females evaluated their sexual experiences subjectively as good (researchers' evaluation: 12), four as satisfactory (researchers' evaluation: two). In two cases the medical evaluation of this area was poor. Explicitly the sexual potential for excitement and the capability of orgasms for the females are presented. Only four females were sexually inactive. Their socio-economic status was marked by seven females as subjectively good (researchers: five), seven as satisfactory (researchers' evaluation: ten) and four as poor (researchers' evaluation: three). The emotional state was subjectively evaluated by 15 females as good (researchers' evaluation: 12) , of two as satisfactory (researchers: four) and for one as poor (researchers: two).
Males: The somatic results are evaluated subjectively by four males as good (researcher's evaluation: five), by two as satisfactory (researchers: one). Three males each evaluated their sexual experiences subjectively as good (researchers' evaluation: four), resp., satisfactory (researchers: two). Their socio-economic status is described correspondingly to the medical evaluation by three males as good, two as satisfactory and one as poor. Again, equal with the researchers' evaluation, five males characterize their emotional state as good, one as satisfactory.

Suicide Attempts/Role Re-reversal
"The general, at least latent, pre-suicidal tendencies decreased strikingly compared to the time before surgery (figures are not given, F.P. & A.J.), so that after that only three male-to-female patients expressed passing suicidal thoughts, while no suicide attempt was made ... Only one male-to-female transsexual had post-surgically the feeling to regret because of his precarious social situation, but not a single one thought about or desired a re-reassignment surgery" (p. 30).

Follow-up Studies Mentioned
Benjamin, 1966; Hastings & Markland, 1978; König et al., 1978; Spengler, 1980, Steiner, 1976

Authors' Conclusion
Overall the results are evaluated as satisfactory. "The ... way of the gender adapting surgery and socio-therapeutic care of this existentially disadvantaged minority is confirmed most clearly by the overwhelmingly high post-surgical satisfaction despite all complications in some partial areas" (p. 31).

Remarks
Remarkable in this publication is the evident evaluation differences between researchees and researchers - especially regarding females, who were evaluated more sceptically by researchers than by the patients themselves. For males, the self- and external evaluation corresponded more closely. Extraordinary in follow-up literature is the information about the additional examinations of females: test excisions of the vagina were taken. The histologic examination showed a metaplasy of the pushed in formerly penis skin as smooth and only discretely horny vaginal skin. This functional adaptation -- about half of the females reported lubrication during sexual excitement -- is attributed by the authors to the effects of estrogens given as well as frequency of sexual intercourse and time since surgery.