Wiegand, 1984
Psychosomatic University Clinic, Heidelberg, Germany

This is a medical dissertation that documents treatment course and treatment results of patients with transsexual symptoms treated at Heidelberg University from the mid-1970s to the time of the study, 1981-83. About two-thirds of the patients came from other cities of the Federal Republic of Germany and from West Berlin, where they had been previously diagnosed and treated, exclusively for the surgical procedure in Heidelberg (performed there since 1976); this decreased motivation to participate in the follow-up study.

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

Study Methods
The author did not participate in the treatment. He conducted semi-structured interviews with 13 females and four males. Five females and one male could only be questioned by phone. All followed-up answered a katamnesis questionnaire. The interview and katamnesis questions are printed in the annex of the publication. Some patients, especially from the Heidelberg region, were seen multiple times, others only once. The partner was also talked to, but in a not specified amount. Four patients each were examined shortly before, resp., shortly after surgery with a Rorschach and Giessen Test. For the anamnesis data, the clinic files and expert opinions were viewed. The evaluation was done by the patients and the author.

Evaluation Fields and Criteria
Sociographic data, especially profession, psycho-social stress, psychodynamic constellation and the influence of the surgery on the inner harmony are described, as well as satisfaction with the results of surgery and the necessity of corrective surgery.

Results
Females: Already pre-surgically eight females had had "a professional demotion by social prestige value or a worsening of their professional situation" (p. 157) that did not continue post-surgically. The measure of post-surgical professional improvement, resp., worsening, was about the same. Post-surgically nine females lived in a partnership; one female had married. Corrective surgery was necessary for four females. Five females had further surgical wishes (breast enlargement, vocal chord shortening, that by the impression of the author, were expressed less urgently than the primary wish for sex reassignment). Emotionally five females felt calmer, more equilibrated and satisfied after surgery. Emotionally and socially three females were notably worsened. These were patients for whom already existing pre-surgically "severe mental symptoms, especially paranoia and querulant personality traits ... worsened after the gender reassignment" (p. 163).
Males: The pre-surgical professional demotions documented for females did not happen for males. Post-surgically the professional situation was unchanged on average. Two males lived in a partnership. One male needed corrective surgery. Three of the five operated "desired energetically a better penis surrogate" (p. 162). Emotionally three of the five felt notably calmer, equilibrated and satisfied by the surgery. One male had notably worsened emotionally and socially; pre-surgically he also had "severe mental characteristics" (p. 163).

Single Case Studies
The course, relatively generalized, of four females and two males are described.

Suicide Attempts/Role Re-reversal
One MFT had committed suicide before the planned surgery. One male had attempted suicide pre-surgically; multiple patients had threatened suicide in the course of treatment.

Follow-up Studies Mentioned
Benjamin, 1964b; König et al., 1978; Kröhn et al., 1981; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1974; Sörensen, 1981a, b; Randell, 1969

Authors' Conclusion
The author does not come to a clear evaluation but mostly annotates his research results.

Indication Recommendations
Bodily outfit or physical appearance that facilitate the life in the other gender role; a multi-year-long exercise in the other gender role; a stable and adapted-to-reality feminine, resp., masculine, ideal ego; professional-practical interest in the surgery (the author means by this, for example, to work as a prostitute after surgery); a partnership that had existed already prior to surgery. As relative contra-indications the following are mentioned: physical appearance that make life in the other gender role harder; age greater than 45 to 50 years.

Remarks
The author had taken on more than he could handle with his widespread study, in which he wanted to work out, besides the reasons of transsexualism, the sociographic, biographic, psychodynamic and social background and aspects of transsexualism all at the same time. As the printed research instrument in the annex demonstrates, he got lost with his own questions as well as the many hypotheses he wanted to check. In the spread-out, realization and presentation of the results, the publication is completely opaque and the results are, finally, just as unusable as the case studies are unclear. The most differentiated is the presentation of the pre- and post-surgical professional situation of the investigated sample.
Represented clearly and understandably are the big difficulties that the author had to motivate patients for the follow-up study. A large majority did not answer multiple written invitations. Patients who were most grateful toward the surgeon who had co-signed the invitation to the follow-up study and those who hoped to express further corrective surgery wishes at the time of the follow-up study could be won the easiest for collaboration, whereas patients who had only used the clinic in Heidelberg for sex reassignment surgery had little reason to have their total development researched again. The sample distortion that happened because of this is not discussed. The frequently cited percentages are incoherent in view of the small case number of the partial sample.