Dudle, 1989
Dept. of Endocrinology, Medical University Clinic and Psychiatric University Clinic, Bern, Switzerland

In the year 1969 a Gender Identity Committee modeled after the American Gender Identity Committees, an interdisciplinary work group for the treatment of transsexuals, was constituted. This medical dissertation describes probably a representative sample (see Remarks) of operated patients from Switzerland by use of the evaluation of clinical files. It diverged from other follow-up studies by its overview ability and the detail precision, comparison of single case results with some from other follow-up studies as well as an extensive discussion of fundamental methodological problems. The sample of the follow-up study Simona-Politta (1983) is included in the present research again. Correlations and deviations of results attained by different methods in both researches are extensively represented and discussed. Also the follow-up study by König et al. (1970a) as well as Zingg et al. (1980) are from the same patient collective but there were no comparing calculations made to these.

• 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 research was based exclusively on an independent evaluation of the clinical files.

Evaluation Fields and Criteria
The following areas are noted and put in relation to the pre-surgical situation: psychopathology, suicidal tendencies, criminal record, economic factors, partnerships and sexuality, treatment complications. (The evaluation criteria were taken partly from Hunt & Hampson [1980a]).
The physical results of the sex reassignment (including all corrective surgeries) was evaluated with the aid of a score system in which the following criteria were included: the external (anatomical) aspects were graded as good (+1), satisfactory (0) and unsatisfactory (-1); in the functional aspects: good (+1) was considered for males if they achieved a problemless excretion function and being free of pain, while for females "additionally the possibility must be give to have a frictionless (sic!) intra-vaginal sexual intercourse" (p. 59); as fair result (0) the slightly problematic excretion function was evaluated, also pain and a significant limited functional capability of the vagina; finally, a bad result (-1) contains a severely problematic excretion function and/or, for females, the anatomic possibility for sexual intercourse. The external appearance of the dressed patient: if adequate to the new gender, a rating of +2; questionable or not adequate, -2.
To evaluate the treatment success from the patient's view a score system with three inherent questions was used: if the patient was satisfied with the gender reassignment (+1), fairly satisfied (0) or not satisfied (-1); if the patient would undergo the surgery again with reservations (+1), with some reservations (0), not again (-1); if the patient regretted surgery (-2) or not (+1). In case a patient did not know an answer to a question, it was evaluated as zero.
The external evaluation was made by the treating physician in three steps (good, fair, bad) by the following three criteria: external appearance, dressed as well as naked, in how far the patient was satisfied with the morphological as well as the functional results, and if the patient accepted oneself in the new gender role; in how far the patient was recognized in the new role in a social environment.

Results
Females: Pre-surgically five females had severe, and four fair psychopathologies. All these patients were classified as secondary transsexuals. Three females each had post-surgically worsened, resp., bettered. Ten females had encounters with the law and were sentenced before surgery - post-surgically, probably two. "It is notable within the results that all criminal acts were attributed exclusively to patients with a severe psychopathology. Also the biological male patients seemed to be worse off, with a criminal rate of 50% before surgery and 11% after surgery than the females - with 9% each" (p. 39).
Post-surgically in the professional area there was a slight improvement in four cases compared to the pre-surgical time and in three cases, a worsening. Self-sufficiency and stability showed no notable differences between pre- and post-surgical values. Post-surgically 39% of the females had a professional-economic situation improvement. Worsening was found for 17%.
"The value to the libido in the medical files had shortcomings because for only half of the cases were there entries about them. The libido for females post-surgically seemed to be at the same level as before surgery. With at least 39% of the females the libido seemed to be strong pre-surgically and in at least half of all cases, normal or stronger" (p. 44). Ten females were sexually satisfied post-surgically, compared to four pre-surgically; only one was not sexually satisfied and pre-surgically this was true for nine. The "orgasm capability" "existed" before surgery in 14 females (p. 45), post-surgically for 12. The sexual activity with a partner was "relevantly greater" (p. 45) post-surgically for ten females. Before surgery seven females lived promiscuously at times and after surgery, 11; while seven were never promiscuous pre-surgically, post-surgically three never were. Three females each were pre-, resp., post-surgically working as prostitutes. Three females worked as prostitutes both before and after surgery.
Before the role change, five females were married, two had children. After the legal gender change four females got married - of whom two were already divorced at the time of the follow-up study and had married again. Seven females lived post-surgically in permanent living situations and dwelling-sharing groups - at least three of which had existed before surgery.
The anatomic result was evaluated for 12 females as good, for five as satisfactory and for none as bad. Functionally 13 classified as good, one as fair, three as bad. To the latter belonged a patient who never wanted a vagina and rejected sexuality and a female who "had as a risk factor a high age and a certain social neglect" (p. 51). All except two females had an appearance that corresponded to the new gender role. The two exceptions were one female who did not take her hormones regularly and even discontinued them at times and the already-mentioned patient who did not get sufficient estrogen therapy because of a lung embolism.
Only one female was subjectively not satisfied with the results of surgery; three were only fairly satisfied. One female was unsure if she would repeat the surgery; all others would have done so even though three announced certain reservations. No female regretted the surgery.
According to the judgement of the treating physician the result of surgery was good for 11 females, satisfactory for six and bad for none.
Males: Pre-surgically two males each had severe, resp., fair psychopathologies. Post-surgically two males improved. One male each had a criminal conviction pre-, resp., post-surgically.
In the professional classification a slight improvement, resp., worsening each was found compared to the pre-surgical data. Self-sufficiency and stability showed no significant differences between pre-surgical and post-surgical values. For 27% of the males there was improvement of their professional/economic situation post-surgically. There was worsening for only 9%.
"The data in the clinical files about the libido was incomplete because records about it existed in only half the cases ... there ... was only a minimal upward trend" (p. 44). Post-surgically seven males were sexually satisfied compared to two pre-surgically; only one was not satisfied sexually post-surgically, where this had been true for four pre-surgically. "Orgasm capability existed" (p. 45) for four males. Eight males report about post-surgical orgasms. Sexual activity with partners was for four males "relevantly greater" (p. 45) post-surgically. Of the males, one behaved promiscuously pre-surgically and probably another one post-surgically. In one case a post-surgical activity as a prostitute was presumed. Before surgery none of the males was married; four were married post-surgically and of these one was filing for divorce at the time of the follow-up study. Five males lived in intact partnership situations, two of which had existed already before surgery.
The anatomic results were classified as good in six cases, as satisfactory in four and as unsatisfactory in one. Without exception the functional results were good and the appearance fitting.
The self-evaluation was also completely good. The question about a neo-phallus, that most patients would have liked in as far as it would have been possible to be made anatomically and functionally satisfactory, was left out.
he judgement of the treating physician about the results of the sex reassignment was "good" in nine cases, "satisfactory" in two and "bad" in none.

Single Case Studies
For all patients the most important results are represented coded in tabular form. Short illustrations from the biographies are given regarding some aspects. Three single case studies are presented extensively. Also those patients not evaluated in the research of the total sample are described in the annex in annotated form.

Suicide Attempts/Role Re-reversal
Females: Pre-surgically two MFTs attempted self-mutilation and another one threatened self-mutilation. Ten MFTs had attempted to commit suicide and one had expressed threats. Post-surgically four females attempted suicide and only one of these had no suicidal tendencies pre-surgically.
Males: Two FMTs attempted suicide pre-surgically. One had expressed threats. Post-surgically one male attempted suicide who had not had suicide tendencies previously. "Remarkable is the post-surgical decrease of suicide attempts from 56% to 22% in male-to-female transsexuals, as well from 18% to 9% in female-to-male transsexuals" (p. 36).

Follow-up Studies Mentioned
Benjamin, 1964a, 1966, 1969; Blanchard et al., 1985; Eicher, 1984; Hamburger et al., 1953; Hastings & Markland, 1978; Hoenig et al., 1970a, b; Hunt & Hampson, 1980b; König et al., 1978; Kröhn et al., 1981; Laub & Fisk, 1974; Lindemalm et al., 1986; Lothstein, 1980, 1982; Lundström et al., 1984; McCauley & Ehrhardt, 1984; Meyer & Reter, 1979; Money & Ehrhardt, 1970; Pauly, 1965, 1968, 1974, 1981; Randell, 1969; Simona-Politta, 1983; Sörensen, 1981a, b; Stürup, 1976; Wålinder, 1967; Wålinder & Thuwe, 1975; Wålinder et al., 1978

Authors' Conclusion
"Summarizing, it can be said that the studies in the course of the 1970s were based increasingly on an exact data compilation and on exactly defined criteria. As results, the pre-quantitative and quantitative research report about a post-surgical improvement of approximately two-thirds of patients" (p. 18). "The results achieved in Bern in sex reassigned transsexuals are good in international comparison. The treatment has shown mostly positive results that are sufficient to justify the severe procedures. Sex reassignment for appropriate true transsexuals can be recommended because of this reason" (p. 76).

Indication Recommendations
The only prognostically unfavorable factor that was found in this study was the existence of another psychopathologic disorder besides transsexualism. "But this does not exclude in any way that patients with severe emotional disturbances could gain by sex reassignment" (p. 75).

Remarks
This publication contains statistics about the development of the numbers of first consultations of patients with transsexual symptoms in the University Clinic of Bern from 1969 to the middle of 1987, as well as the number of sex reassignment surgeries in Bern during the same time period (pp. 60-62). With regard to the prevalence ratios calculated by Wålinder (1967) as well as Hoenig & Kenna (1974), the in -Bern-realized sex reassignments would correspond to 49% of the surgeries to be expected for MFTs, resp., 69% of those to be expected for FMTs in Switzerland.
The single case studies demonstrate that the pre-surgical treatment did not correspond to the published treatment principles (König et al., 1978) and the requirement for a one- to two-year-long Real-Life-Test before the indication for surgery was made. Two patients were under guardianship or legal aid pre-surgically; even under conditions of incarceration the treatment was started. The case studies clearly show that it was more about satisfying individual patients than about general principles. A severe shortcoming of the publication is that it bases mainly on the evaluation of clinical files and retrospective external evaluations, not on immediate follow-up studies.