Eicher, 1984
Dept. of Gynecology, Diakonissen Hospital, Mannheim, Training Hospital of the University of Heidelberg, Mannheim, Germany

This is the first German monograph about transsexualism with explicit representation of the term as well as symptoms, aetiology, diagnostic, differential diagnostic and treatment. Especially the hormone treatments and surgical procedures are extensively described. The following data was extracted from chapter X: "Therapeutic Proceeding, part 5: Results and Satisfaction with the Procedures." The emphasis of the publication is not on the aspect of follow-up studies.

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

Surgical Complications
In the surgical breast enlargement: Capsular fibrosis in one gel prosthesis (n=1), discrete hardening of a saline solution prosthesis (n=2), immediate post-surgical hematomas (n=6), re-examination necessary (n=3). For the vaginoplasty: secretion continence with abscess forming between the implanted penis skin and prostate (n=1, removed by puncturing incision), hematoma below the labia majora, resp., the mons pubis (n=4, removed by puncturing incision), recto-vaginal fistula with consecutive vaginal shrinking (n=1, fixed after six months), shortening, resp., tightening of the vagina (n=8, fixed in four cases). Vagina entrance too wide (n=1, repaired by perennial building up). With surgical breast reduction: partial nipple necrosis "rarely" (p. 133). With hysterectomy and adnectomy: severe leg vein thrombosis (n=1, six months of anti coagulation treatment). With clitoris penoid: stenosis of the urethra exit (n=1, additional orifice), fistula (n=1), repeated rejection of the silastic testes prosthesis (n=1), one-sided rejection of one silastic testicle prosthesis (n=1), capsular fibrosis (n=1).

Study Methods
The author seems to have recorded clinical impressions non-systematically.

Evaluation Fields and Criteria
"The evaluation of a therapy depends in a decisive way on the success of the employed methods. The methods consist of cross-sexual hormone therapy and surgical adaptation. The goal is, as far as possible, masculizing or feminizing. Further than this, in transsexualism the total situation after the transformation has to be evaluated, of which the mental equilibrium and the ability to communicate as well as the integration into the surroundings are part. The latter can be measured by the socio-economic situation and the stay at the workplace, as well as interpersonal relationships, especially partnerships, and most particularly by sexual attitude. The satisfaction of patients depend on all these factors. Non-satisfaction can be determined by the desire for corrections, the wish for the former state, a worsening of emotional stability as noted by suicidal tendencies, psychoses, depression and severe neuroses" (p. 147).

Results
Females: For ten percent of the females, in whom it came to a vaginal stenosis or shortening as well as for one patient who was unhappy about a too-wide vaginal entrance and too small labia, were dissatisfied about local findings that also decreased sexual experience capability. In those cases where local findings were successfully altered, the females were satisfied afterward. In the sexual area, 80% of the females were "with a functioning vagina, capable of orgasm during intra-vaginal co-habitation" (p. 147). The author supposes that the socio-economic situation for two females -- who did not come for the follow-up study and in whom the vagina had shrunk because of lack of dilation -- has worsened. About 25% of the females lived in lasting partnerships, two of whom were married. None of the operated regretted the surgery and also declared if it were the case again, they would once more opt for surgical adaptation. All had had a legal sex change.
Males: For the males, "There is a general satisfaction about the surgeries done in different extents; each of them would again try for a surgical adaptation. The patients who did not have a phalloplasty are emotionally rather more stable than those who underwent multiple surgeries and corrections to obtain a labia penoid. In the last group there is a patient who became an alcoholic and was unsuccessful in social integration as a nurse. All other patients were able to generate normal socio-economic situations after the transformation and legal sex change" (pp. 147) or to maintain it. Sixty percent of males had permanent partnerships and nine of them got married. Ninety-five percent of males had sexual relationships. "The ten patients with a clitoris penoid are all emotionally stabilized and do not regret this solution, with which they can urinate standing. But the majority await that they someday will be given a normal-sized erectile penis" (p. 148).

Single Case Studies
In the monograph, there are many case studies tossed in about the pre-surgical life situation and about treatment of the patient to illustrate generalized findings.

Indication Recommendations
Without insuring the pre- and post-care, a surgical intervention against transsexualism is near malpractice. As most important contra-indications, the following are mentioned: criminal past, in as far as it has nothing to do with transsexualism; psychoses, lacking agreement of the spouse for married subjects; a not-100% sure diagnosis; age of minority; the impossibility of a physical adaptation to the other gender; the danger of triggering a socio-economic and cultural crisis; lacking intelligence and reasoning ability; impossibility or lacking will to cooperate as well as lacking readiness to participate in the post-surgical care. "Also the unwillingness to explicitly declare that the physician will not be held liable for the consequences of the procedure with a correct carrying out of surgery is a reason for exclusion" (p. 79).
Also it is presupposed that the Real-Life-Test was done successfully for at least a year, that hormone treatment of at least half-a-year has been well received and that the indication was confirmed by expert opinion. Generally the prognosis for younger patients is evaluated as more favorable. Fundamentally there should be no surgery before the 18th birthday, but there are exceptions where there should and could be a deviation of this rule.

Suicide Attempts
Pre-surgically 15% of the MFTs had attempted suicide; one had committed suicide. Of the FMTs, 10% had attempted suicide. Pre-surgically depressive crises had occurred in 65% of all patients. Six percent of MFTs had attempted self-mutilation; one had castrated himself. Self-mutilation attempts (cut scars on the breasts) were found in 2% of the FMTs (p. 24). Post-surgically no suicide attempts or suicides were observed.

Follow-up Studies Mentioned
Benjamin, 1964b, 1966; Hamburger et al., 1953; Hastings & Markland, 1978; Hoenig et al., 1971; Hunt & Hampson, 1980b; Jayaram et al., 1978; König et al., 1987; Kröhn et al., 1981; Laub & Fisk, 1974; Meyer & Reter, 1979; Money & Brennan, 1968; Pauly, 1965, 1968, 1974, 1981; Randell, 1969; Sörensen, 1981a, b; Steiner, 1976; Stürup, 1976; Turner et al., 1978; Wålinder & Thuwe, 1975; Wålinder et al., 1978; Wyler et al., 1979

Authors' Conclusion
"Generally, it can be said that the patients with the best surgical results express the highest satisfaction and are adapted best professionally and to their environment and that is why they are also emotionally stabilized the best" (p. 147). The author draws the conclusion from the existing follow-up studies that suicidal tendencies of successfully operated transsexuals is no higher than among the general population.

Remarks
As mentioned at the beginning, this book is the first German-language monograph about transsexualism. It gives a good overview about the theme, for professionals as well as for patients. For counseling patients, the illustrations are particularly helpful. While normally in professional literature about transsexualism the somatic and psycho-social aspects are almost always represented separately, here the attempt has been made to unify these two aspects. Most of all, the author intended a total presentation in the frame of which in very few pages treatment results are briefly compiled.