Lundström 1981
Department of Psychiatry and Neurochemistry, St. Jörgens Hospital, University of Göteborg, Sweden

By design this is a parallel study to the follow-up study of Wålinder & Thuwe (1975) with the difference that here exclusively those patients were included for whom the indication for sex reassignment surgery was expressively refused. Lundström researched, deviating from all follow-up studies referred to here, how the refusal affected the patients long-term. The sample describes patients for whom either a diagnosis of transsexualism was not confirmed from the beginning or for whom other factors led to the refusal of the patients' request for surgery. Three groups were compared: (1) personally followed-up and not operated (n=17), (2) personally followed-up but, despite of denial, operated somewhere else (n=4) and (3) not personally followed-up, operated and not operated (n=10).

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

Diagnosis and Indication Criteria
The diagnosis transsexualism was made if the patients were convinced since childhood to belong to the opposite sex, refused their gender-specific body characteristics, tried to gain recognition as a member of the other gender, insisted on hormonal and surgical treatments and desired a corresponding legal sex change. Hormonal and surgical treatment were done if, besides this, the indication conditions named in Wålinder & Thuwe (1975) were given.

Reasons for Refusal
The reasons to deny the hormonal and surgical treatment are compiled in two different tables (table 7, p. 56 and table 8, p. 58). The first of these tables names general reasons and the second uses the denial decisions with diagnostic viewpoints (comp. remarks).

Study Methods
Methodologically the author was oriented toward the research of Wålinder & Thuwe (1975). With those belonging to groups 1 and 2, a two-hour interview that can be characterized as a combination of a free and standardized interview was conducted. The standardized questions were oriented on the Rating Scale for Post-Surgical Transsexuals (Hunt & Hampson, 1980a). The research sample contains ten patients who could not be personally followed-up but about whom ample clinical files and external information existed. Additionally for every patient information from the social registers and criminal records were obtained and the entries in the data file of the governmental Swedish insurance funds was checked - where, since 1955, for all workers over 16 years of age, all sick certifications and diagnoses and work disabilities and disability pensions are documented. Additionally, all clinical records of the patients from psychiatric institutions were added. (Details of the statistical analysis for the compiled data can be found in Lundström, 1981, p. 69.)

Evaluation Fields and Criteria
Additional to the scale of Hunt & Hampson (1980a), the criteria analogous to Wålinder & Thuwe (1975) the sexual preference, strength of libido, work record and living conditions were evaluated. Additionally, cross-dressing was evaluated (constantly; only at times; only underwear).
Group 1 was asked how they accept their biological sex role (no acceptance; partial or compelled acceptance; acceptance).

Results
Because this is not primarily a follow-up study of operated, we will not report about all results and do divide the results into those for males and females, but follow the grouping by the author.
Group 1: With two exceptions, the cross-gender identity experience was present for the whole time of the follow-up study for all others. The two exceptions are two males who were 17 years old at the time of the first examination who seemed to be rather effeminate homosexuals and for whom transsexual symptoms had no intensity. Both lived by then as homosexuals.
Ten (eight MFTs, two FMTs) of the 17 patients considered the refusal of their application in retrospect as wrong, five considered it right. Six (four MFTs, two FMTs) still hoped to be operated at some point; some stayed in contact with the clinic because of this. Eleven had come to the conclusion that it made little sense to actively pursue the desire for surgery after so many years. Only six males had given up the desire for surgery and the cross-dressing and lived as homosexuals.
Eleven of the 15 MFTs had to have in or outpatient psychiatric treatment during the time of the follow-up study (comp. Suicide Attempts).
The total score using the rating of Hunt & Hampson (1980b) was 18.2 points and was, therefore, between the values for the pre-, resp., post-surgical evaluations of the 17 females researched by Hunt & Hampson (1980a).
Group 2: For three patients surgical treatment was finished; for one it had just started. All four patients considered the previous refusal of their application wrong and were satisfied by the then-achieved results. Also according to the evaluation of the author the situation of the patients -- that pre-surgically were very difficult which contributed that they were not admitted for surgery -- had improved notably. The total score using the rating of Hunt & Hampson (1980b) was pre-surgically 7.0 and post-surgically 22.3.
Group 3: The only FMT in this group had committed suicide shortly after the denial decision. Three MFTs had been operated somewhere else. Three of the remaining six patients developed psychiatric symptoms and were incapacitated to work for a long time. Overall -- for the seven patients of the group about whom sufficient information was available -- a cross-gender identity still prevailed.

Single Case Studies
The courses of patients of groups 1 and 2 are documented extensively (pp. 130-183). For patients of group 3 the more important data that was available is shared (pp. 95-99).

Suicide Attempts/Role Re-reversal
From group 1 three patients attempted suicide before the denial decision; four other patients had serious suicidal thoughts. After the denial decision, seven patients attempted suicide, four of them repeatedly. Most of the suicide attempts were in relation to the denial decision. Pre-surgically, one FMT in group 2 had attempted suicide. Post-surgical suicide attempts were not observed. About suicide attempts of patients in group 3 nothing is shared in regard to the time before the denial decision. After this time, nothing is known about suicide attempts of these patients, about whom only meager follow-up study data was available. The only FMT of this group committed suicide as a reaction to the denial decision. About role re-reversal, see above.

Follow-up Studies Mentioned
Benjamin, 1966, 1967; Hastings, 1974; Hertz et al., 1961; Hoenig et al., 1970b, 1971; Hore et al., 1975; Hunt & Hampson, 1980b; Kröhn et al., 1981; König et al., 1978; Laub & Fisk, 1974; Lothstein, 1980; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1965, 1968, 1974, 1981; Randell, 1969; Stone, 1977; Stürup, 1976; Sörensen, 1981a, b; Turner et al., 1978; Wålinder & Thuwe, 1975

Authors' Conclusion
Overall, the living circumstances of those who were not supported in their desire for a life in the other gender's role were more disharmonious than for those who underwent surgery. Transsexual symptoms that already appeared in childhood and adolescence seem to indicate that these symptoms will persist. Among the FMTs, none, and among the MFTs diagnosed as genuine transsexuals, very few abandoned the desire for sex reassignment. With obsessive-compulsive cross-dressing, a harmonization with the gender role corresponding to the physical attributes was extremely difficult. MFTs who were diagnosed borderline effeminate homosexuals (no rejection of their own genitalia, great interest in homosexual contacts) had greater chances to get along long-term without surgical intervention.

Indication Recommendations
In addition to the generally accepted indication recommendation by Wålinder & Thuwe (1975), a conclusion is drawn from the results that obsessive-compulsive cross-dressing should reinforce the surgery indication in as far as the other prerequisites are met. It can also be concluded that biographical data and present behavior that expresses transvestite or effeminate homosexual aspects should conduce rather to a reservation for the surgery indication. The psycho-sexual functioning level remains mostly untouched whether or not someone was operated, according to the evaluation of the author, and plays no important role for the surgery indication. The aspect that is mostly to be regarded is that patients with low psycho-sexual functioning level have greater difficulties to cope with the stress of the change.

Remarks
This careful publication is instructive because it does not only ask the question about courses and treatment results, but also about the effects of differential diagnostic decisions that were made contrary to the desires of the patients. It demonstrates that in comparison to the patients immediately admitted for surgery, among the differential diagnostically much more heterogeneous group of the rejected patients, a great percentage of patients can be found who would gain by treatment; the percentage of those in whom the transsexual symptoms is lost throughout the years is very small.
From a content viewpoint, that is all-deciding here, in the comparison of operated and non-operated patients the group division chosen by the author that is oriented under methodological procedures is somewhat confusing because group 3 does not represent its own group by its membership. The division of the persons from group 3 would have been more overviewable had the persons of group 3 been put into the other groups.