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

This publication connects to Sörensen (1981a) and describes the results of a partial sample of males (FMTs) examined with the same instrument who had been operated at the Copenhagen University Psychiatric Clinic since 1956. With them, Sörensen & Hertoft (1980a) could not make such a clear differentiation in core and border groups as with the females (Sörensen, 1981a). The narcissism problem expresses itself in males as phallic narcissism that serves as defense against fear and identity insecurity. Because of this reason, males are sexually more active because they have to demonstrate to themselves and others their phallic strength. Female homosexuality and FM-Transsexualism are described as continuum.
In the follow-up study the hypothesis is tested and affirmed that treatment results are better the more stable the transsexual symptoms could fight off the fears on which they were founded pre-surgically. The more alloplastic the personality is structured, the more it is to be expected that the sex reassignment is to be experienced as dissatisfactory.

• 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 males were interviewed by the author, guided by a standardized questionnaire.

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
Pre-surgically three males were employed, four lived from unemployment benefits or social welfare and one received a medical disability pension. Post-surgically, four each were employed, resp., received a medical disability pension. Seven had lived for at least six months after surgery in partnerships with a female. Two had gotten married. Their own children or children of partners lived in four households.
As complications of the hormone treatment, once an edema is mentioned and once a thrombosis. Two males had evidently neither pre- nor post-surgically any hormone treatments. Only three of eight wished for corrective surgery (scar correction on breasts, correction of the phalloplasty). Only four were satisfied with the surgical results.
All were diagnosed and treated psychiatrically over varying time periods (see above), without their subjective impression that they had needed it. In retrospect, six thought bitterly about the treatment and only two with satisfaction. Two had required post-surgically psychiatric help.
Post-surgically all eight males had sexual intercourse exclusively with females. Five were then sexually more active than before and also more satisfied.
In a global evaluation of the post-surgical course, six of the eight called themselves absolutely satisfied, two as dissatisfied. One male regretted the surgical procedure; it was the male who had heavy secondary reactions to hormone treatments and additionally had partnership problems - because of which he frequently thought about suicide.

Single Case Studies
As a demonstration, three case studies were presented extensively, namely the successful development of a patient with a non-alloplastic rejection structure, the rather unsuccessful development of a patient with alloplastic defense structure and finally the history of a male who circumvented the rejection decision of the treating physicians and underwent surgery elsewhere.

Suicide Attempts/Role Re-reversal
Pre-surgically three males had attempted suicide, post-surgically none. Despite this, one sometimes had, in connection with partnership problems, suicidal thoughts and regretted the surgery without making the attempt to reverse into the previous gender role. The third case describes a male who does not belong to the follow-up study group because he was not accepted for surgery in the Rigshospitalet for being pre-psychotic. He achieved surgery elsewhere and six months after surgery, made a suicide attempt with barbiturates.

Follow-up Studies Mentioned
Benjamin, 1966; Hoenig et al., 1971; König et al., 1978; Money & Ehrhardt, 1970; Pauly, 1974; Vogt, 1968; Wålinder, 1967; Wålinder & Thuwe, 1975

Authors' Conclusion
Just as with the females (Sörensen, 1981a), the author sees the sex reassignment as a symptomatic, not causal treatment, for the males. The results are more convincing the more stable the patients are and the more modulated, resp., alloplastic the phallic/narcissistic structure is. The length of the follow-up study does not change the results.

Indication Recommendations
For patients with a developed alloplastic personality structure or pre-psychotic or those with an unstable defense, surgery should not be recommended.

Remarks
As already for Sörensen (1981) this is one of the few of the follow-up studies in which an author has a theoretical concept to understand transsexual symptoms, that he at the same time uses for a differential surgery indication. The follow-up study confirms the hypothesis that generally more stable patients gain more from treatment than unstable patients. It is remarkable that three-quarters of the males described here retrospectively do not evaluate the pre-surgical psychiatric treatment lasting up to more than five years positively - which probably demonstrates that this treatment did not fit the needs of patients. Because one does not learn anything about the type of intervention or frequency, the sense or nonsense of pre-surgical treatment cannot be deduced.