Transsexuals who had not undergone surgery, although it had been offered to
them providing they fulfilled the usual requirements, were classified into
various subgroups, measured according to their attitude towards sex
reassignment surgery: they were transsexuals with an unaltered wish for
surgery, transsexuals who were ambivalent towards surgery (hesitating
patients), and transsexuals who had relinquished their wish for surgery and
lived in the initial gender role. Whereas transsexuals with an unaltered wish
for surgery did not differ substantially from transsexuals who had had
surgery, the hesitating patients were noticeably older, more often married,
more often had children of their own, their partnerships were of long
duration, and exclusively with partners of the opposite biological sex. These
characteristics were seen when the diagnosis was first made. They can
therefore be considered prognostic criteria for this subgroup. Transsexuals
who relinquished their wish for surgery did not differ substantially from
transsexuals with an unaltered wish for surgery. The reasons for
relinquishing the wish for surgery were individual or could not be clearly
established. At the time of follow-up, all transsexuals who had not undergone
surgery indicated that they were experiencing the same degree of difficulty
with respect to social adjustment as at the time of diagnosis. Slight
improvements were seen in patients with an unaltered wish for surgery.
Significant changes were seen only in transsexuals who had surgery.
Transsexuals who have not had surgery and have no present wish for it are in
the minority. Hesitating patients have a particular need for psychotherapy.
KEY WORDS: transsexual; prognostic criteria; follow-up; sex-change surgery.
1The study was supported by a grant from the Wilhelm-Sander-Stiftung.
2Dedicated to Prof. D. Ploog for his 65th birthday.
3Department of Psychiatry, Technical University, Mohlstrasse 26, 8000
Munchen 80, Germany.
4To whom correspondence should be addressed.
Long-term follow-up studies of transsexuals who have not had surgery are
rare. Meyer and Reter (1979) were the first to carry out a detailed study of
transsexuals who had not had surgery. From the results obtained they
concluded that gender reassignment surgery does not achieve more for
transsexuals therapeutically than if they adopt a policy of wait and see and
are admitted to a program that could later make gender reassignment surgery
possible. This report has been criticized, particularly by Fleming et al.
(1980) The criticism is directed partly at the system used by Meyer and Reter
for evaluating social integration; it is also pointed out that the results
from the groups formed by Meyer and Reter do not provide suitable material for
drawing conclusions about the therapeutic effectiveness of gender reassignment
surgery. In 1981, using the data from a follow-up examination, Krohn
described 13 male-to-female transsexuals who had not yet had surgery and whose
diagnosis had been established 4 to 8 years before. Nine of these, mostly
over 40 years old, lived in their aspired role, in which they were accepted;
they neither had nor wanted sexual contacts. They still said they wanted
surgery, but had not actively taken any steps in that direction for years.
They were described as mentally stable and their socioeconomic situation free
of problems. Lundstrom (1981) conducted a thorough follow-up study of 31
patients, who at least 3 years earlier had wanted gender reassignment surgery.
According to his results patients "with conditions difficult to distinguish
from effeminate homosexuality or classical transvestism" can come to terms
relatively well with their biological sex, whereas cross-dressing behavior of
a compulsive type is an indication for sex reassignment. McCauley and Erhardt
(1984) reported on the follow-up of 15 female-to-male transsexuals, of whom 6
who had not had surgery, and did not live in the male role, or did not live in
it all the time. All six reported a recurrence of strong transsexual wishes
in stress situations or when they were depressed.
From these reports it can be concluded that in follow-up studies
transsexuals who have not had gender reassignment surgery show a variety of
attitudes towards it: Some still urgently want surgery, others are ambivalent
towards surgery, and some have decided against it.
The aim of our investigation was to see whether subgroups of this nature
could be ascertained and to determine how they differed. In view of the
results of the Meyer and Reter (1979) study, we were particularly interested
in the question of whether sex reassignment surgery actually influences the
psychosocial situation of transsexuals.
This survey included all patients who were examined by one of the authors
in a Psychiatric Outpatient Clinic during the period from January 1, 1970 to
December 31, 1980 and diagnosed according to the diagnostic criteria of the
DSM III (American Psychiatric Association, 1980) as transsexuals. Particular
care was taken to differentiate between transsexualism, transvestitism, and
homo-sexuality using the criteria of Lundstrom et al. (1984) in addition to
the DSM III criteria. The first consultations had to be at least 2 years
prior to the follow-up. According to these criteria a total of 80 patients
were selected from the case histories. In the course of consultations with
the patients they were all offered the possibility of gender reassignment
surgery on condition that they fulfill the usual requirements such as 1 or 2
years counseling, a "real-life test," and hormone treatment (see Sigush et
al., 1979; Fahrner and Kockott, 1984).
The basis of the follow-up was a personal interview. With few exceptions,
the interviews were not conducted by those who had initially treated the
patients. In the 2 to 3 hour interview (Transsexuals Follow-up Interview,
TFI) the following areas of life were covered by 125 questions: occupation,
partnership and sexual behavior, relationship with family, circle of friends,
relationship to the sex role, and somatic conditions. The TFI is a
semistructured interview with open and closed questions. After the interview,
the interviewer evaluated the patient's social and mental adjustment according
to a specially developed four-stage rating scale (Psychological Integration of
Transsexuals, PIT). This rating scale was developed according to the scale
used by Hunt and Hampson (1980). Fifteen interviews were conducted by two
interviewers who rated the persons separately. The overall interrater
reliability was r = 0.79 using the Spearman-Brown prediction formula. In the
nine psychosocial areas covered by the interview, patients were evaluated as
to how they coped socially and emotionally. The evaluation of their degree of
the psychological difficulty was carried out according to a manual. A total
number of points was calculated from the nine subscales of the PIT.
Times of Assessment
Data are available for three assessments of the transsexuals who underwent
gender reassignment surgery and data for two assessments of the transsexuals
who did not have surgery. Information on Assessment 1 (A1), when the
diagnosis was made (usually after the first five consultations), are available
for both groups. Details of Assessment 2 (A2), in the period shortly be fore
gender reassignment surgery, are only available with regard to the
transsexuals who underwent surgery. The data for both assessments were
collected retrospectively from the case histories. For these a shortened
version of the TFI (Evaluation Sheet for Case-Histories, ECH) was used as well
as the rating scale PIT. Assessment 3 (A3) is the follow-up study.
Description of Sample
Of 80 patients (100%), 59 (74%) were interviewed. Four patients (5%)
refused to take part in the investigation, four patients (5%) could not be
interviewed for organizational reasons, and three patients (4%) died. The
addresses of 10 patients (13%) could not be ascertained. Of the patients
interviewed, 32 underwent sex reassignment surgery, 27 transsexuals had not
yet had surgery. The average duration of the follow-up period, beginning from
the time the diagnosis was made, was 5.5 years for the total sample. For the
group of patients who had had surgery, it was 6.5 years, and for the group of
patients who had not had surgery 4.6 years.
Table I. Demographic and Socioeconomic Status of Transsexuals (N = 58)
Transsexuals who had not had surgery --------------------------- (n = 26)
who have for surgery Hesitating
Variable (n =32) (HP) n = 7 n = 12 n = 7
Age in years 35.5 40.3 31.7 3l.8
(SD = 13.1) (SD = 9.4)b (SD = 10.2)b (SD = 6 5)b
Male to female l8 (56%) 6 (86%) 9 (75%) 4 (57%)
Female to male 14 (44%) 1 (14%) 3 (25%) 3 (43%)
Single 21 (66%) 3 (43%) 11 (92%) 6 (86%)
Married 3 (9%) 4 (57%)a 1 (8%)a 0 (0%)
Divorced 8 (25%) 0 (0%) 0 (0%) 1 (l4%)
Number of transsexuals
of their own 3 (9%) 4 (57%)a 0 (0%)a 1 (14%)
of their own 29 (91%) 3 (43%) 12 (100%) 1 (86%)
employee 14 (44%) 2 (29%) 3 (25%) 3 (43%)
Civil servant 3 (9%) 2 (29%) 0 (0%) 1 (14%)
occupation 11 (34%) 0 (0%) 5 (42%) 3 (43%)
Self-employed 2 (6%) 3 (43%) 1 (8%) 0 (0%)
Student 2 (6%) 0 (0%) 3 (25%) 0 (0%)
aSignificant difference (5% level) between HP and UWS.
bDifference at the 10% level between HP, UWS, and IG.
The Subgroups (Table l)
At the time of the follow-up assessment (A3), three subgroups could be
differentiated among the patients who had not had surgery according to their
wish for gender reassignment surgery: (i) Patients with an unchanged wish for
surgery during the whole follow-up period (UWS: 12 patients, 9 male-to-female
and 3 female-to-male transsexuals). They had not yet fulfilled all the
requirements for surgery such as intensive counseling, real-life test, etc.
At the time of interviewing most of them were at the real-life test stage.
(ii) Patients who remained undecided during the whole follow-up period, the
hesitating patients (HP: 7 patients, of whom 6 were male-to-female
transsexuals and one was female-to-male). They lived mainly in their
biological sex role. (iii) Patients who at the time of the follow-up
assessment had not wanted gender reassignment surgery for some time. They
lived in their original biological sex (IG = initial gender: 7 patients, 4
male-to-female and 3 female-to-male transsexuals). Only one patient lived
completely in the aspired gender role without gender reassignment surgery.
This patient is not included in the following comparison.
Table II. Differences Between the Three Subgroups
of Transsexuals Who Have Not Had Surgery (UWS, HP, IG)
at the Time of the Follow-Up Assessment (A3)
Variable Subgroups Phi Fisher two-tailed P
Own income 7 of 12 7 of 7 0.456 0.106 (58%) (100%)
sufficiency 6 of 12 7 of 7 0.519 0.044a (50%) (100%)
partners 0 of 5 2 of 2 1.0 0.048a (0%) (100%)
High value placed
on sex 9 of 12 2 of 7 0.454 0.077 (75%) (29%)
identity 12 of 12 3 of 7 0.676 0.009b (100%) (43%)
Satisfied with home
situation due to
transsexuality 12 of 12 3 of 77 0.676 0.009b (100%) (43%)
of long duration 0 of 9 2 of 4 0.640 0.077 (0%) (50%)
satisfaction 1 of 6 6 of 77 0.691 0.029a (17%) (86%)
sexual arousal 2 of 7 6 of 7 0.774 0.103 (29%) (86%)
aSignificant at the 5% level.
bSignificant at the 1% level.
Differences Between the Subgroups
at the Time of the Follow-Up Assessment
The hesitating patients seemed to be different from the others. They
tended to be older than the other subgroups, they more often had their own
children and were significantly more often married than the UWS patients
(Table I). The socioeconomic situation of the hesitating patients was more
stable. They more frequently tended to have an income of their own than with
patients with an unchanged wish for surgery. They managed significantly
better financially. The current partnerships of the hesitating patients,
although mainly unhappy ones, had existed for a significantly longer period
and, compared to patients within an unchanged wish for surgery, were only with
sex partners of the opposite biological sex. Hesitating patients were
significantly less satisfied sexually than the IG patients. They also felt
less affinity towards the aspired gender. They were significantly less
satisfied with their home situation due to their transsexuality (Table II).
The PIT questionnaire for determining the psychosocial adjustment of
transsexuals showed no difference between the three subgroups at the time of
the follow-up assessment, although the IG group achieved slightly better total
scores (see Fig. 1).
Development of the Three Subgroups
During the Follow-Up Period
The patients' descriptions of their situation given at the time the
diagnosis was made (A1) were compared with those given at the time of the
follow-up assessment (A3).
For patients with an unaltered wish for surgery (UWS), job satisfaction had
increased during this time and their transsexuality was more often accepted by
family members. Partner relationships deteriorated in that partnerships that
had existed before the wish for gender reassignment surgery was clearly
expressed came to an end. In the PIT (Fig. 1) the total score improved from
20.2 to 18.7. This difference is not, however, significant. Both scores
still indicated obvious difficulties with psychosocial adjustment.
Fig. 1. Psychosocial adjustment of operated and
three groups of unoperated transsexuals (rating scale PIT).
For hesitating patients (HP), neither the follow-up data nor the PIT showed
Patients with no present wish for surgery (IG) showed an increase with
respect to sexual satisfaction. There were no significant changes in the PIT.
When the diagnosis was made this subgroup was psychosocially the best adjusted
of all the subgroups. They reported only a few psychosocial difficulties
The Subgroups at the Time the Diagnosis Was Made
We assumed that the subgroups described would be distinguishable when the
diagnosis was made. To confirm this, the statements made at the time of the
diagnosis (A1) by the three subgroups of patients, UWS, HP, and IG, that were
formed later were compared with one another. Since this involved a
retrospective evaluation of case histories, only a descriptive comparison is
possible due to incomplete data. Again it was the group of patients who later
hesitated about surgery who were noticeably different when the diagnosis was
made: Their average age was considerably higher than that of the other groups
of transsexuals who had not had surgery and the majority were married men with
children of their own. Compared with patients with an unaltered wish for
surgery, of whom only half were satisfied with their jobs when the diagnosis
was made, the hesitating patients and those who later no longer wished for sex
reassignment surgery (IG) were all satisfied with their jobs when the
diagnosis was made. The PIT (Fig. 1) does not show significant differences,
although, as already described, the psychosocial integration of the IG group
was clearly better than that of the other subgroups when the diagnosis was
Does Sex Reassignment Surgery
Influence the Psychosocial Situation of Transsexuals?
Indirect indications of the effect of sex reassignment surgery can be
obtained by comparing the statements of patients who have had surgery with
those of patients with an unaltered wish for surgery at the time of the follow
up assessment. We therefore compared the statements of the 32 patients of our
sample who had had surgery with those of the UWS subgroups (12 patients) who
were particularly suitable for comparison as they showed no differences with
respect to sociodemographic data (see Table I).
Table III. Differences Between Transsexuals Who Have Had
Surgery (SU) and Patients with Unchanged Wish for Surgery (UWS)
at the Time Follow-Up Assessment (A3)
Variable SU UWS Correlation x2 P (two-tailed)
No employment 2 of 32 4 of 12 3.379 0.066 (6%) (33%)
sufficiency 27 of 29 6 of 12 7.484 0.006b (93%) (50%)
satisfaction 28 of 32 5 of 11 5.924 0.015a (87%) (45%)
aspired gender 31 of 32 5 of 10 10.112 0.002b (97%) (50%)
Well adapted to
gender role 30 of 32 5 of 12 11.525 0.001c (94%) (42%)
aSignificant at the 5% level.
bSignificant at the 1% level.
cSignificant at the 0.1% level.
Transsexuals who had had surgery were significantly (Table III) more often
well or very well adjusted to the aspired gender role, although all UWS
patients were already living in the aspired role. Their socioeconomic
situation had also improved during this period. Although unemployment was
rare in our sample, transsexuals who had surgery tended to be even less
frequently unemployed than the transsexuals who had not yet had surgery. In
addition, the transsexuals who had surgery coped significantly better
financially. Suicide attempts during the follow-up period were a rare
occurrence. By contrast with the UWS patients, however, suicide attempts had
become significantly (p = 0.040) less frequent among transsexuals who had
surgery. As expected, the transsexuals who had surgery were significantly
more satisfied with their gender role and also with their sexual experiences
(Table III). According to the PIT results, the transsexuals who had surgery
were significantly better adjusted psychosocially than the transsexuals who
had not yet had surgery but had an unaltered wish for surgery (Fig. 1). The
UWS patient group was accordingly still reporting marked difficulties, while
the total score of the transsexuals who had surgery indicated only a few
difficulties in the psychosocial area. At the time the diagnosis was made the
PIT showed no differences between these two groups.
The transsexuals who after an average follow-up of 4.6 years had not had
surgery, although it had been offered to them provided they fulfilled the
usual requirements, were not a homogeneous group. Our results showed three
subgroups differentiated according to their attitude to gender reassignment
surgery: transsexuals with an unaltered wish for surgery, the hesitating
patients (HP, Group 2), and transsexuals who relinquished their wish for
surgery and lived in the initial gender (IG, Group 3).
According to the previous literature (Krohn, 1981; Lundstrom, 1981) there
appears to be a further subgroup of transsexuals: those who live in the
aspired gender role without having surgery (Group 4). Only one female-to-male
transsexual from this subgroup was among our clients. It may be possible to
put all transsexuals who have not had surgery into one of these four
categories. The transsexuals who had not had surgery described by Meyer and
Reter (1979) can largely be categorized as hesitating patients - they were
still interested in gender reassignment surgery without however undertaking
the appropriate preparatory steps. Five transsexuals had relinquished their
wish for surgery and would therefore belong to Group 3 (IG). Six of the 12
genuine transsexuals in the Lundstrom study (1981) had surgery during the
follow-up period. Of the six who had not had surgery, three still wanted it
(UWS, Group 1), two had given up their wish for sex reassignment (IG, Group
3), and one had committed suicide. McCauley and Erhardt's transsexuals who
had not had surgery can also be added to Group 2 and 3. In all the studies,
including the present one, the transsexuals who had not had surgery, but who
had no present wish for surgery were a minority by comparison with the
transsexuals who had surgery and the transsexuals who had not had surgery but
wished for it.
The differences between the subgroups with respect to the sociodemographic
and psychosocial data were instructive, particularly as far as the hesitating
patients were concerned. The distinguishing variables found made the
hesitation about gender reassignment surgery understandable: These were well-
established people who would have had to give up a lot. The variables
mentioned were however insufficient to explain the hesitation: Even among
transsexuals who had had surgery, there were established transsexuals with
children of their own, although there were significantly fewer of them.
Our study showed that the patients who had relinquished their wish for
surgery and continued to live or lived again in their initial gender role did
not differ significantly from patients with an unaltered wish for surgery.
The only difference was that long-standing former partnerships were more
common. Reasons for giving up the wish for an operation differed widely and
were highly individual: socioeconomic reasons, a highly valued job that could
only be carried out in the initial gender role, or development of a meaningful
partnership that was only possible in the biological gender role. A few
transsexuals could not give any real reason for their decision. All of them
uniformly renounced surgery, although the decision had been made with varying
degrees of difficulty.
Transsexuals fulfilling the criteria of patients who later hesitated about
having surgery could be recognized at the time the diagnosis was made, that
is, at the time therapeutic contact was first established. Such patients
should be studied particularly carefully because there is much evidence that
the aspired gender change has not been psychologically worked through. It is
interesting to note that some of the factors that were found by Walinder et
al. (1978) to correlate with an unfavorable outcome of sex reassignment
surgery can be seen in our groups of hesitating patients, namely, heterosexual
experience and a higher average age at the time contact was first made. Other
factors however do not fit the description of our hesitating group, such as
unstable personality, criminality, and inadequacy, with respect to self-
support. This group of transsexuals should however still receive intensive
counseling with the aim of getting them to make a decision that has been
properly thought through in order to avoid an unfavorable outcome of surgery.
As expected, the subgroups developed differently during the follow-up
period, when all patients received psychiatric and social counseling.
Transsexuals with an unaltered wish for surgery were the only group who made
improvements, although in our measurements these were not statistically
significant. The improvement with respect to their occupations were one of
the conditions for surgery, as this was only to take place if social and
mental stabilization had been achieved. The improved relationships towards
parents and siblings were more likely due to psychiatric care during the
follow-up period. Transsexuals who relinquished their wish for surgery
experienced greater sexual satisfaction. This could be interpreted as a sign
that they had come to terms with their decision not to have an operation. As
expected, there were no changes whatsoever during the follow-up period as far
as the hesitating patients were concerned. All transsexuals who had not had
surgery reported the same marked difficulties with psychosocial adjustment as
at the time the diagnosis was made, although the IG group had fewer
difficulties than the others. This was different only for the transsexuals
who had surgery. It is thus necessary to find therapeutic ways of helping
those transsexuals who do not want to undergo surgery.
When the results of transsexuals who have had surgery are compared with the
UWS group, there is distinct evidence of the stabilizing effect of gender
reassignment surgery. However this comparison is only of limited value as it
concerns two subgroups of a sample, even though the sociodemographic data are
comparable (see Table I). The more convincing comparison of the results of
three assessments of transsexuals who had surgery (carried out when the
diagnosis was made, shortly before surgery, and during follow-up) are
described elsewhere (Fahrner et al., 1987), and show not only the positive
effect of sex reassignment surgery (for the psychosocial integration of
transsexuals) but also the positive effect of a long period of preparation for
sex reassignment. There psychiatric and social counseling as well as
presurgical living in the aspired gender role is necessary for adequate
adjustment. This is in agreement with the findings of Blanchard et al.
Further investigations should aim at clarifying the motivation of some
transsexuals to relinquish or postpone their wish for surgery, as well as
trying to find how they can be therapeutically helped to cope with their
continuing difficulties with gender identity.
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