Sörensen, 1981a
Psychiatric Clinic, University Clinic Copenhagen (Rigshospitalet), Copenhagen, Denmark

The author had, together with Hertoft (Sörensen & Hertoft, 1980a), developed a clinical theory oriented on the phenomena about the dynamic coherence of transsexual symptoms and differentiated between the core group of transsexuals, who are characterized by their stable pseudo-feminine narcissism, a low intensity of genital sexuality and a stable ego strength and -- if one disregards the transsexual symptoms -- have an intact reality testing; and other transsexuals. For them, the transsexualism is no stable defense structure. The wish for sex reassignment is fluctuating and they have more genital interest.
With this follow-up study the hypothesis is checked and confirmed that the transsexuals of the core group (n=14) gain much more by the hormonal and surgical sex reassignment than all other transsexuals (n=9). (In the results representation, it is always expressed in parenthesis for how many of the core group a characteristic applies.)
It is unclear how many of the females from the follow-up study by Stürup (1976), whom the author cites without debating the contents, are again included in this follow-up study. Single case studies as well as follow-up study periods indicate severe overlap. While in Stürup, objective shortcomings of the treatment were a clear theme, in Sörensen unsuccessful treatment is interpreted almost exclusively in connection with the personality traits of the treated.

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

Study Methods
The females were interviewed by the author with a standardized questionnaire. If the author participated in the treatment cannot be discerned from the publication.

Evaluation Fields and Criteria
In the questionnaire and interview the following themes were compiled: social situation (employment and profession, social level, satisfaction with income, marital status, relations to own children and their reaction to the sex reassignment, social contacts, living conditions). Physical well-being (illness, cosmetic problems, hormone treatment, further surgery wishes). Surgery complication, satisfaction with surgical results, emotional well-being (in and outpatient psychiatric treatment, use of psychopharmacology, alcohol use, suicide attempts, present and pre-surgical well-being). Sexual behavior (time period of the first post-surgical sexual intercourse, partner, masturbation frequency, orgasm experience). Evaluation of the treatment (pre-surgically, during surgery and post-surgically). In as far as it is possible with every one of these themes, pre-surgical data is shared. The emphasis was on the subjective evaluation of the questioned. The evaluation criteria of the author are not shared.

Results
Social situation: While pre-surgically 15 (11) females had steady employment post-surgically it was only nine (six). Pre-surgically two (none) received medical retirement pay and six (three) received unemployment benefits. After surgery ten (five) received medical retirement benefits and four (three) unemployment. Fourteen (12) females experienced their economic situation as good, nine (two) as bad. At the time of the follow-up study, 17 (12) females lived alone, six (two) with a partner. Ten (four) had post-surgically lived for at least six months with a partner. Eight (two) of them had serious problems with the partner. Thirteen (ten) of the females had felt socially isolated before surgery and 16 (ten) after surgery. Ten (three) females had problems with their neighbors. Four (two) had children of their own, but only one (none) lived post-surgically with the children.
Subjectively 16 (13) females were satisfied with the results of the surgery and seven (six) dissatisfied. Eleven (five) females wanted further surgical procedures. In detail, seven (three) wanted corrective surgery of the vagina, five (one) a breast enlargement and four (two) cosmetic facial corrections (more than one choice was possible). These desires were statistically independent of the time interval passed since the primary surgery. Five (two) females had to constantly wear wigs because of advanced hair loss and 14 (eight) had on-going problems with facial hair growth. Pre-surgically eight (four) had been psychiatrically examined stationary or treated and post-surgically one (none). Alcohol and drug abuse had increased slightly. About 75%, namely 17 (14), declared that their expectancies and hopes had been fulfilled. Even larger was the proportion of those who considered their emotional well-being as better in comparison to the time before surgery (19[14]).
Nine (four) females initiated sexual activities (sexual intercourse) during the first six months after surgery, eight (six) after half-a-year and six (four) had no sexual contacts post-surgically. All 17 (10) females who had sexual relations had them with males. Four (two) said that they experienced orgasms during sexual intercourse. Many had functional problems or fears. Ten (six) females tried to keep their sex reassignment a secret from their partners. Subjectively satisfied with their sexual life were seven (five) females, just as many as were dissatisfied. Three females were extremely dissatisfied in this area.
In a global evaluation of the post-surgical course, 18 (11) females were satisfied, three (three) very satisfied, two (none) dissatisfied and none very dissatisfied.

Single Case Studies
The development of three patients who committed suicide post-surgically is represented extensively. Two of them started treatment at age 45, resp. 54. None of the three belonged to the core group. The indication for surgery was carefully thought over for each and the prognosis was evaluated rather sceptically. One patient was explicitly not admitted for surgery and had later been operated in England.

Suicide Attempts
In the publication six (three) pre-surgical suicide attempts are registered for three patients; also there are indications of severe suicidal danger and threats to be taken seriously. Post-surgically three (zero) suicides were registered (see single case studies).

Follow-up Studies Mentioned
Benjamin, 1966; Hamburger et al., 1953; Hertz et al., 1961; Jayaram et al., 1978; König et al, 1978; Money, 1971; Money & Ehrhardt, 1970; Pauly, 1965; Stürup, 1976; Wålinder & Thuwe, 1975

Authors' Conclusion
The author compiles results in a direction that indicates that the advantages of sex reassignment surpass its disadvantages, in as far as the core group is concerned. Sex reassignment is not a causal but a symptom treatment. To the contrary of Money & Ehrhardt (1970), Money (1971), Wålinder & Thuwe (1975), König et al. (1970a), he does not see surgical sex reassignment as an adequate instrument for resocialization. To the contrary, post-surgically more lived from medical retirement pay, about 66% lived alone and sexual relationships were problematic. Despite the 66% who were satisfied with the results of surgery, 50% desired additional surgical procedures. Post-surgically none of the patients became psychotic and 83% of the females felt better than before surgery. In regard to the results, the length of the follow-up study period did not have any influence.

Indication Recommendations
For transsexual patients who do not belong to the core group, that is, in whom the cross-gender identification is not stable, the subjective and objective problems seem to be so great that a sex reassignment should be discouraged, regardless in which extreme and subjectively not satisfying situation the patient is (p. 487). At least the question must remain open if such patients should be operated or not (p. 502).

Remarks
This is one of the few follow-up studies that, guided by theory, distinguishes between different groups to work out differential diagnostic indication criteria. Naturally the results confirm in a form of a circle the starting hypothesis that simplified can be formulated like this: Healthier patients profit more from the treatment than sicker patients. The publication is impressive because of its methodological clearness and overview ability.
Partially the results are worked out with simplification that we consider problematic: Permanent surgical wishes should not, for example, be evaluated as themselves as signs of unsatisfactory treatment results without regarding that this also could be an expression of a justified desire. Such subjective statements can only be evaluated when the objective results of the previous surgery, resp., hormone treatment, is documented, which one misses in this publication.