Fahrner, Kockott & Duran, 1987
Psychiatric Clinic of the Technical University Munich and the Max-Planck-Institute for Psychiatry, Munich, Germany

This publication researches the question if there are differences between the emotional and social stabilities of operated, reps., non-operated transsexuals. This is a course research with three measuring time points, namely after the intake interview, before surgery and at the time of the follow-up study. It is remarkable that the emotional stability and social stability improve already between the time of the diagnosis and the time of the indication for surgery, not only post- surgically, even though in the post-surgical time period more positive changes happen.

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

Study Methods
Of the operated there is data for three measuring time points. The statements for the first two time points -- after finishing the diagnostic phase (as a rule, five interviews) and shortly before the sex reassignment surgery -- were taken retrospectively from clinical files. For the non-operated there is data for two measuring time points (retrospective statements from files for the time after finishing the diagnoses as well as the time of katamnesis).
For the follow-up a two- to three-hour structured interview (a questionnaire designed by the researchers "Katamnesis Interview Transsexualism" [KIT]) with a total of 125 open-ended and closed questions that was not done, with a few exceptions, by the former care provider. After the interview an external evaluation of the emotional and social adjustment was made by the interviewer using a four-step rating scale that was developed for it (questionnaire developed by the researchers, "Psychological Integration of Transsexuals" [PIT]). To check the reliability of the PIT, 15 patients were evaluated by two interviewers. (Correlation coefficient r=0.79) Additionally the patients answered psychological questionnaires (Insecurity Questionnaire [Ullrich de Mynck & Ullrich, 1976]; Depression Scale [von Zerssen, 1976]).

Evaluation Fields and Criteria
The following life areas were asked about in the interview and after that, evaluated on a four-step rating scale (none, light, noticeable and severe difficulties): professional situation, financial situation, social relations net, reaction of the family, satisfaction with the partnership situation, satisfaction with the sexual situation, physical status, the behavior of the surrounding toward the gender role, one's own behavior toward the gender role.

Results
The results are given in the following only for those operated and is not divided into gender because the publication does not contain such a division.
Professional situation: (PIT: none/slight difficulties: 81%). Only two of the 32 operated are unemployed. Permanent employment is held by 26 (81%); two are in professional training and two receive a retirement pension. No professional demotions were found. The transsexualism is known at the workplace for 51%, but only one patients says that there are noticeable to strong difficulties to get along with the general working conditions and with the situation as a transsexual in the workplace.
Financial situation: (PIT: none/slight difficulties: 92%). The majority of the operated live completely from their own income or retirement pension (87.5%); five patients said that they had to limit themselves financially because of transsexualism.
Social relations net: (PIT: none/slight difficulties: 91%) In most cases (75%) at the time period of katamnesis there was a strong contact to friends and acquaintances and the transsexualism is accepted by the family members. Sixteen percent of the questioned had no stable circle of friends.
Psychiatric status: (PIT: none/slight difficulties: 88%) After the sex reassignment surgery, 81% of the previous patients were no longer in psychiatric treatment. Alcohol abuse was determined for one as sure and presumed for two others. Subjectively, the majority (97%) got along with their lives better or much better compared to the time period before the surgery.
Partnership situation: (PIT: none/slight difficulties: 69%) Forty one percent of the operated lived in permanent partnerships; ten had not entered into any partnerships since surgery; the other nine had only short-term partnerships.
omatic status: Twelve females have a vagina adequate for sexual intercourse. The majority of the males (n=11) have no, resp., a non-functioning phallus. Subjectively 78% of the patients are satisfied or very satisfied with the surgical results.
Sexual experience: (PIT: satisfaction: none/slight difficulties: 88%) Among the 53% who experience sexual excitement frequently as well as among the 48% who frequently experience orgasm are more females than males. As problems in the sexual area, nine patients say that there are physical difficulties and seven cite the low frequency of sexual contacts. Sixty three percent are satisfied, resp., very satisfied with their sexual experience. In comparison to the time before surgery, the sexual experience did not worsen for anyone. Compared to the time period before surgery, 25 (89%) experience their sexuality as more satisfying, three (11%) as unchanged.
Gender identity: The majority of the patients (97%) are satisfied or very satisfied with their new gender role. Only one is rather unsatisfied. No one regretted having opted for surgery.

Suicide Attempts
Since the sex reassignment surgery a total of three patients attempted suicide and of those, one patient twice.

Follow-up Studies Mentioned
Benjamin, 1964b, 1966; Hastings, 1974; Hoenig et al., 1970a, b, 1971; Hunt & Hampson, 1980b; König et al., 1978; Kröhn et al., 1981; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1968; Randell, 1969; Sörensen, 1981a, b; Spengler, 1980

Authors' Conclusion
"Overall one can presuppose that the sex reassignment surgery contributes greatly to the psycho-social stability, but this only under the premise of a careful diagnosis and a good -- timewise not too short -- caregiving as preparation for the surgery and the desired gender role" (p. 347).

Indication Recommendations
Careful diagnosis as well as a good and not too short in time caregiving as preparation for surgery and the desired gender role. Pre-surgical testing of the new gender role.

Remarks
The research demonstrates that part of the improvements of the psycho-social situation develop already in the course of pre-surgical caregiving. This affirms the importance of a sufficiently long pre-surgical treatment phase. It is also remarkable that those operated fared noticeably better regarding the dimension of the psycho-social integration and the depressive tendencies than those who were not operated. The latter are divided into three groups by the authors: 1. A "preparation group," that is, patients who are scheduled in a foreseeable time for a sex reassignment surgery; 2. "Vacillators" who vacillate regarding a surgical wish and 3. A small group that has decided to keep the original gender role. In depression measured with the aid of the von Zerssens Depression Scale, the smallest is in those who underwent surgery. Within the sub-group of those not operated, its measure is the smallest in group 1 (preparation group) and the highest is within group 3 (original gender role).