Eicher, Schmitt & Bergner, 1991
Dept. of Gynecology, Diakonissen Hospital, Mannheim, Training Hospital of the University of Heidelberg, Mannheim, Germany

This is a follow-up study of patients who the primary author had operated after publication of his monograph and after the one-time procedure described there (Eicher, 1983, 1984). Described are surgical techniques, results of a written questionnaire, as well as extensive personal commentaries of the females.

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

Study Methods
The primary author had operated all females and also did their physical follow-ups. The clinical files about the course of in-patient treatment and the statements of the females on the questionnaires were also evaluated.

Evaluation Fields and Criteria
Statement about post-surgical complications were taken from clinical files. In the written questionnaires the subjective satisfaction, partnership, sexual behavior, depth, width and lubrication of the vagina, sexual experience as well as the socio-economic situation were compiled. Finally, the females were asked for freely formulated comments.

Results
Severe complications immediately post-surgically were not observed. "The question if they would undergo surgery again was answered in the affirmative by 39 patients (97.5%). One patient did not answer. One patient said that she regretted the surgery. Thirty-eight of the polled (95%) felt reinforced in their identity as females and experience themselves sexually as females" (p. 124).
"Six of the polled lived with the previous male partner and six with the previous female partner (15% each). Twelve (30%) had separated. Twenty-six patients (65%) felt attracted to males, five (12.5%) to females and eight (20%) to females as well as males. Five patients (12.5%) lived with a female partner and 11 (27.5%) with a male partner. Independent if they lived with somebody, fourteen of the polled (35%) had sexual relationships with a male or female partner. Fifteen polled (37.5%) had changed partners since surgery, 11 of them multiple times and two of them six times each" (p. 124).
"Eighteen patients (45%) were very satisfied with the function of the vagina, seven (17.5%), resp., 11 patients (27.5%) considered it good, resp., satisfactory; only three (7.5%) were unsatisfied. The depth of the vagina was evaluated by 16 patients (40%) as good, by 15 (37.5%) as being satisfactory and by eight (20%) as too small. The width of the vagina was found appropriate by 25 patients (62.5%); eleven (27.5%) considered it narrow and two (5%) as too narrow. The vaginas of eighteen patients (45%) became lubricated during sexual excitement. This reaction appeared on average 14.7 months after surgery (minimum one month, maximum 50 months). Because of dryness of the vagina, 20 of the polled (50%) used a gel" (p. 124). Of three of the ten females who did not return their questionnaires it was know that the vagina was stenosized, which was partially attributed to the lacking cooperation with dilation.
"While strong sexual desire was felt by five of the polled (12.5%), most (26=65%) considered their sexual desire as average; nine (22.4%) said to feel sexual desire seldom or never. Twelve patients (30%) had vaginal intercourse regularly, nineteen (47.5) irregularly and nine (22.5%) not at all. Of the 31 polled with intercourse experience, six (19.4%) always came to orgasm, 50 (48.4%) frequently, five (16.1%) seldom and four (12.9%) never. It is remarkable that half of the patients affirmed the questions if they had feelings in the freely transplanted clitoris. To the question were they felt the strongest excitement, 50 (35%) indicated the vaginal entrance, urethra opening and clitoris; 70 (42.5%) said the vagina and 24 (60%) answered 'all over my body' (multiple answers were possible). As further sources, oral sex was indicated by ten (25%) and anal sex by two patients (4%)" (p. 124).
"Economically 26 of the polled (65%) had improved since surgery, one (2.5%) worsened. For the rest, the economic situation was unchanged. Twenty-three patients (27.5%) still worked in their previous professions. Thirteen (32.5%) had changed professions and four (10%) did not have work. Before and after surgery only three (7.5%) had no regular income. Eleven polled (27.5) did not have a regular income before surgery, but had such at the time of the follow-up study. Only one patient lost her income after surgery. For slightly more than half of the polled, the income after surgery was higher (17.5%), resp., noticeably higher (35%), for nine (22.5%) it stayed the same and for another nine it was less than before surgery" (pp. 124).

Follow-up Studies Mentioned
Eicher, 1983, 1984; Fahrner et al., 1987; Hamburger et al., 1953; Herms, 1989; Kröhn et al., 1981; Pfäfflin & Junge, 1990; Turner et al., 1978

Authors' Conclusion
"In the German follow-up study of operated male-to-female transsexuals of the last years .. the usefulness of surgery was not fundamentally questioned anymore" (p. 130).

Indication Recommendations
Certifiable diagnosis based on an at least one-year-long care by a knowledgeable therapist who recommended hormonal and surgical treatment. This indication must be equal to at least two explorations by a surgeon.

Remarks
This follow-up study connects to the previous publications of Eicher (1983, 1984) and especially with the explicit comments of the patients to Benjamin's monograph (1966). The emphasis is on surgical questions and correspondingly the evaluation of the "function" of the vagina takes up much space. Questions about emotional well-being were done only very globally and questions about supportive psychotherapeutic counseling and its effects were not compiled.