Lindemalm, Körlin & Uddenberg, 1986
Dept. of Psychiatry and Psychology, Karolinska University Hospital, Stockholm, Sweden

The authors did not participate in any way in the treatment or indication of the followed-up persons. They believe their high rate of non-success, about 30%, to be more accurate. Although it deviates from the rest of the follow-up study literature -- with a maximum of 20%, which they call still too high -- they think that they are, to the contrary of other researchers, more free (than other researchers) because they do not have to justify their work.

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

Study Methods
With 11 of the 13 females two psychiatrists together, who did not participate in the treatment or indication, held semi-structured interviews of three to six hours. The sessions were taped, transcribed and evaluated by each of the interviewers separately using an evaluation scheme developed by the authors. (An exact presentation of the methodological proceeding was announced for a later publication.) Information about two females who could not be interviewed were taken from clinical records. The surgical results were evaluated from the files and the subjective statements by the females. Four females were examined and rated by gynecologists and surgeons. Two females refused a physical examination. For them, the surgical results were evaluated alone by the file and existing reports of previous findings.

Evaluation Fields and Criteria
For the global evaluation of the psycho-social adjustment the following seven areas were evaluated in the pre-surgical as well as the post-surgical situation and from this, a sum score was formed and compared. Justified by space reasons in the publication, only definitions of extreme values (1=very poor and 4= good) were indicated - not the values in between: 2=poor and 3=fair (pp. 209-210).

For the global evaluation of the sexual adjustment the strength of the libido, sexual activity with one partner, number of partners, sexual orientation and quality of the partnership relations were regarded. Finally, the researchers evaluated the physical appearance of the females.

Results
The surgical results were evaluated by the authors overall as unsatisfactory (comp. the remark to the section Type of Treatment). Two female vaginas were too short, both by self-evaluation and external evaluation. One female, despite good surgical results, had pain during intercourse. For three females the surgical results were evaluated in the external evaluation as excellent, even though one had self-evaluated them as being poor.
Regarding the viewpoint if the female post-surgically opened the vagina with the use of a dilator as recommended by the surgeons, only two females were uncooperative, while three others could not make a dilation because of poor surgical results or an improvement could not be expected by it.
The sexual adjustment was unchanged in the global evaluation for nine females; for three it had improved and for one it had worsened. Six females experienced orgasms in connection with different sexual practices post-surgically. Six females felt attracted to males pre- and post-surgically; three who had had contacts to males and females pre-surgically had only contacts to males post-surgically; one female classified herself as a lesbian.
In regard to partnership relations pre-surgically all patients were evaluated as poor or very poor. Post-surgically the evaluation was better for five females and for one it was worse.
Compared to the pre-surgical situation the evaluation regarding the psycho-social global evaluation had improved for four females; for one it had worsened and for eight it was unchanged. Five females had improved professionally, four had worsened. The relationship to family, friends and partners improved slightly, but the mental health rather worsened.

Single Case Studies
All patients were known by a fictional first name. The results in most areas are given in annotated form specified by person without enabling forming with the many dispersed mosaic pieces the personality characteristics or biographical data.

Suicide Attempts/Role Re-reversal
One female had committed suicide shortly after surgery. She was not regarded in the follow-up study. One patient lived again as a male and fought to be legally recognized again as a male. Another patient lived with a female mate more or less in a male role.

Follow-up Studies Mentioned
Hertz et al., 1961; Hunt & Hampson, 1980b; Lundström, 1981; Pauly, 1981; Pomeroy, 1969; Randell, 1969; Sörensen, 1981a, b; Stürup, 1976; Wålinder & Thuwe, 1975

Authors' Conclusion
Overall the authors think that for four patients the indication for sex reassignment was to be evaluated in retrospect as failed indication. They came to this conclusion by not only considering the explicit repentance about the surgery (one patient) but also the indirect repentance remarks as well as the overall bad social adaptation as a sign for a wrongly indicated surgery. By this, they come to a non-success rate of 30%. They discuss if a high rate of disappointing surgical results are due to the relatively insufficient surgical techniques of 1954-74, especially because between cosmetically and functionally good surgical results and a favorable "sexual adjustment" a positive statistic trend (p=0.18) was found. They deem further long-term follow-up studies as necessary to work out factors that are prognostically favorable and important for the indication.

Remarks
Compared to the flat success notices of many methodologically little elaborated follow-up studies presented here, this publication impresses, especially because the authors treat a wide spectrum of questions and analyze more extensively than many other publications the results of other follow-up studies. Exact examination of their data shows that they also proceed selectively. For example, their statement -- that except for Hertz et al. (1961), Hunt & Hampson (1980b) and Wålinder & Thuwe (1975) there is no other follow-up study in literature with follow-up study results in time periods of more than three years -- is not true.
In this study remarkable are -- apart from the longer than average follow-up study time -- the indications when the patient presented themselves for the first time instead of only measuring the post-surgical time, as well as the wide spectrum of questions. Despite this, only the surgical intervention is accepted as treatment and independent variable. In how far above this patients had other psychiatric or psychotherapeutic help is not even questioned by the psychiatrists who led the research.
In as far as the single case studies allow evaluations, it is impressive how badly the patients were operated and that they had to fight for years for the legal recognition of their new gender roles. Professional demotion and isolation in as far as they are reported about are not to be considered simply as immediate but as least as secondary consequences of a gender reassignment.
The authors' search for indirect regret expressions or signs lets us suppose a rather overly critical prejudice that does not consider that transsexualism has to be understood as a more or less successful stabilizing symptom forming, in which the subjective experience of "success" weighs more heavily than objective clinical files and surgery reports. This is why it is viewed by us as critical that two females who could not be interviewed were regarded in the evaluation anyway and that the surgical and sexual results for two females who refused the physical examination were simply evaluated as negative.
By giving fictitious first names to females whose personal data naturally had to be kept confidential, the authors suggest a familiarity with the females and their biographies that does not necessarily stem from follow-up studies of three to six hours with two unknown psychiatrists. Even if it is right that a follow-up researcher who participated in treatment can have a positively tending prejudice, a follow-up study researcher who explores patients six to 25 years after surgery should think what types of expectations and hopes he activates by it. That the representation of the subjective experience can be distorted just as much as an earlier treatment giver is not reflected in this publication.