Transsexuals Who Have Not Undergone Surgery 
A Follow-Up Study 1,2 
G. Kockott, M.D.,3,4 and 
 E.-M. Fahrner, Ph.D.3 

   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) 
                Transsexuals            wish 
                who have                for surgery     Hesitating
                had surgery

   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 
   with children 
   of their own        3 (9%)     4 (57%)a     0 (0%)a        1 (14%) 
   without children 
   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 
   UWS     HP 
   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%) 
   Cross gender 
   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%) 
   UWS     IG  
    Former partnership 
    of long duration        0 of 9           2 of 4    0.640      0.077        (0%)    (50%) 
   HP      IG 
   satisfaction               1 of 6           6 of 77   0.691      0.029a    (17%)    (86%) 
   Frequency of 
   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 
any changes. 
   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%) 
   Content with 
    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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