Pfäfflin & Junge, 1990
Dept. of Sexual Research, Psychiatric Clinic and Dept. for Psychosomatics and Psychotherapy, Medical Clinic, University Hospital Hamburg-Eppendorf, Hamburg, Federal Republic of Germany

This follow-up study describes a sample with approximately the same proportion of females and males. This research was done in collaboration with the University of Minnesota Medical School, where it was planned to expand on the follow-up research started previously by Hastings & Blum (1967), Hastings (1974) and Hastings & Markland (1978). It was designed so that a comparison with the unfinished research there would be possible. The sample contains seven females who were followed-up already by Spengler (1980) and the males described by Junge (1987).

• Sample
• Results
• Suicide Attempts
• Authors' Conclusion

Study Methods
The research was based on the following sources and procedures: (1) Evaluation of the hospital files. (2) Interview of one to four hours, as mean two and a half hours in length. (3) Physical examination (females), resp., inspection of the surgical results (males) and photographic documentation. (4) Katamnesis questionnaire. (5) Independent evaluation of the results by two researchers, at least one of whom did not participate in treatment.
Katamnesis questionnaire: For the standardized compiling of the katamnestic life situation, a German translation of a questionnaire developed and tested for sex reassignment surgery (Satterfield et al., 1981, unpublished) was used. The questions refer to the following areas: medical treatment, professional development, family, friends, partnerships, sexual experience, general and emotional well-being. From the answers, a scaled value for the professional, social and emotional situation of the subject for the previous 12 months can be determined and can then be compared, as a self-evaluation, to an external evaluation of these areas.
External rating of the pre- and post-surgical life situation: The pre-surgical living situation of patients was evaluated by the primary author, who knew some of the patients from previous or current treatments, by evaluating clinical files. The evaluation of the katamnestic well-being was scored independently from information gained in semi-structured interviews by both researchers participating in the interviews. When only one interviewer was present, the second opinion came from the interviewer's written or taped records.
Statistical evaluation: The inter-rater reliability was r=.87 for the sample of males and r=.83 for the sample of females.

Evaluation Fields and Criteria
For both times there was an external evaluation of the professional, social and emotional situations on a four-step scale whose values (according to Satterfield et al., 1981, unpublished) were determined as follows:

Results
Emotional, social and professional situations: The evaluation is that the post-surgical situation has improved significantly (p>0.01) as a mean in all areas mentioned in comparison to the pre-surgical evaluation. This is valid for females and for males. With exception of the social contacts scale, there were no significant differences in the self- or external evaluation for males and females.
The results of the pre-post comparison on the four-step scale show the greatest changes in the mental health (a mean improvement of 2.29 scale points for females and 2.07 scale points for males) and the smallest in the evaluation in the professional situation (a mean improvement of 1.13 scale points for females and 1.26 scale points for males). Worsening was the exception and regarded exclusively the professional and social situations. In detail, there were the following results:
Females: Only about half of the females had permanent employment (n=18; 47.4%) at the follow-up time, but three of four (n=29;72.5%) were able to provide for their own support. One-quarter of the females needed financial support and were very unhappy with their professional situations. In as far as employment existed, the previous transsexualism was not known to colleagues and only one female each had on occasion, resp,. sometimes, difficulties at the work place because of it.
At the time of the polling, 23 females (56.1%) lived in a permanent partnership. In the year previous to the polling, only ten females (24.4%) had had no partner. Thirteen females (46.6%) could keep their previous transsexualism a secret from all partners with whom they had been since surgery. Three-quarters (n=28, 75.7%) selected mostly or exclusively males as sexual partners; nine (24.3%) preferred females. Only five females (11.9%) did not enter into sexual relationships. Of the sexually active females, 25 (69.4%) affirmed the question if they experienced orgasms. Subjectively 33 females (78.5%) evaluated their general emotional state in the year previous to the polling as good or very good. Eight females (19.5%) were in outpatient psychotherapeutic treatment. One female had been multiple times hospitalized in psychiatry during the previous year.
Males: More than three-quarters of the males (n=33; 76.6%) at the time of the follow-up had lasting employment and were capable of providing for their own lives. Almost 80% (n=35) were satisfied with their professional situation. The work colleagues generally did not know anything about the previous transsexualism, but one male had problems at the workplace because of it.
At the time of follow-up 31 males (72.1%) lived in a lasting partnership. In the year previous to the polling, only eight males (18,6%) had had no partner. Four males (10.4%) had been able to keep the previous transsexualism a secret from their partners. The sexually-active males had selected exclusively (n=35; 89%) or mostly (n=4; 10.3%) females as partners. Four males (9.3%) had not entered into a sexual partnership after surgery. Eight males (19.5%) expressed non-satisfaction with their sexual experience.
Thirty-five males (83.3%) evaluated their emotional well-being in the year before the polling as good or very good. Five males (11.9%) were in psychotherapeutic treatment. One male had been hospitalized multiple times in psychiatry during the previous year.
Surgical results: The maximum score (16) in the evaluation of surgical results for females by cosmetic and functional viewpoints was reached only once. Point values of 14, resp., 15 were reached twice; 13 points four times, 12 points five times. The lower scores (11 points once, ten points four times, nine points three times, eight points twice and seven points once) described results that were subjectively and objectively unsatisfactory. The cosmetic results were evaluated for the males mostly as very bad (seven times; 20%) or as bad (11 times; 34%). Only nine persons
(25%) were evaluated as being good and eight persons (22%) very good. There was a significant correlation (p=0.01) in the overall evaluation of surgical results by the researchers and the answers of the questionnaire about satisfaction with the appearance of the breasts for the males (r=.58), resp., satisfaction about the appearance and function of the female genitals (r=.55).

Suicide Attempts
Three females (7.2%) had attempted suicide during the 12 previous months. One male had attempted suicide when, additional to the difficulties about the first name change and legal sex change (he did not have German citizenship and thus could not make use of the German Transsexual Law), the health insurance wanted ex-post-facto to reject paying the surgical costs.

Authors' Conclusion
"Nowadays a valid treatment maxim, even though not respected everywhere, is that to transfer a transsexual for a surgical procedure or to administer hormones without sufficient counseling is seen as malpractice. For many of the statistically represented patients here, this rule was surely not regarded sufficiently. Especially those females who had come into possession of hormones on the black market and underwent surgery in Casablanca, Morocco, had done this frequently on their own account and had never been under regular medical care in their home country. Surprising as the overall positive results were, it has to be admitted that the scales and evaluation procedures used in the follow-up study are an extraordinarily rough pattern not adequate to record the many appearance forms of individual suffering. To be especially highlighted are the results that the global ratings of the external evaluation correlate closely with the self-evaluations and also that statistically significant worsenings were not found any place and that, even regarding single case studies, are an exception."