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Harry
Benjamin Standards of Care
(The Harry Benjamin International
Gender Dysphoria Association, Inc. (HBIGDA))
Original draft prepared by:
The founding committee of the Harry Benjamin International Gender
Dysphoria Association, Inc.
Paul A. Walker, Ph.D. (Chairperson)
Jack C. Berger, M.D.
Ricilard Green, M.D.
Donald R. Laub, M.D.
Charles L. Reynolds, Jr., M.D.
Leo Wollman, M.D.
Original draft approved by :
The attendees of the Sixth International Gender Dysphoria
Symposium, San Diego,California, February 1979
Revised draft (1/80) approved by :
The majority of the membership of the Harry Benjamin
International Gender Dysphoria Association, Inc.
Revised draft (3/81) approved by :
The majority of the membership of the Harry Benjamin
International Gender Dysphoria Association, Inc.
Revised draft (1/90) approved by :
The majority of the membership of the Harry Benjamin
International Gender Dysphoria Association, Inc.
Distributed by :
The Harry Benjamin International Gender Dysphoria Association,
Inc.
As of the beginning of 1979, an undocumentable estimate of the number of adult Americans hormonally and surgically sex-reassigned ranged from 3,000 to 6,000. Also undocumentable is the estimate that between 30,000 and 60,000 USA citizens consider themselves to be valid candidates for sex reassignment. World estimates are not available. As of mid-1978, approximately 40 centers in the Western hemisphere offered surgical sex reassignment to persons having a multiplicity of behavioral diagnoses applied under a multiplicity of criteria.
In recent decades, the demand for sex reassignment has increased as have the number and variety of possible psychological, hormonal and surgical treatments. The rationale upon which such treatments are offered have become more and more complex. Varied philosophies of appropriate care have been suggested by various professionals identified as experts on the topic of gender identity. However, until the present, no statement of the standard of care to be offered to gender dysphoric patients (sex reassignment applicants) has received officifor sex reassignment has increased as have the number and variety of possible psychological, hormonal and surgical treatments. The rationale upon which such treatments are offered have become more and more complex. Varied philosophies of appropriate care have been suggested by various professionals identified as experts on the topic of gender identity. However, until the present, no statement of the standard of care to be offered to gender dysphoric patients (sex reassignment applicants) has received official sanction by any identifiable professional group. The present document is designed to fill that void.
Harry Benjamin International Gender Dysphoria Association, Inc., presents the following as its explicit statement of the appropriate standards of care to be offered to applicants for hormonal and surgical sex reassignment.
3.1 Standard of care.
The standards of care, as listed below, are minimal requirements
and are not to be construed as optimal standards of care. It is
recommended that professionals involved in the management of sex
reassignment cases use the following as minimal criteria for the
evaluation of their work. It should be noted that some experts on
gender identity recommend that the time parameters listed below
should be doubled, or tripled. It is recommended that the reasons
for any exceptions to these standards, in the management of any
individual case, be very carefully documented. Professional
opinions differ regarding the permissibility of , and the
circumstances warranting, any such exception.
3.2 Hormonal sex reassignment.
Hormonal sex reassignment refers to the administration of
androgens to genotypic and phenotypic females, and the
administration of estrogens and/or progesterones to genotypic and
phenotypic males, for the purpose of effecting somatic changes in
order for the patient to more closely approximate the physical
appearance of the genotypically other sex. Hormonal
sex-reassignment does not refer to the administration of hormones
for the purpose of medical care and or research conducted for the
treatment or study of non-gender dysphoric medical conditions
(e.g., aplastic anemia, impotence, cancer, etc.)
3.3 Surgical sex reassignment.
Genital surgical sex reassignment refers to surgery of the
genitalia and/or breasts performed for the purpose of altering
the morphology in order to approximate the physical appearance of
the genetically-other sex in persons diagnosed as gender
dysphoric. Such surgical procedures as mastectomy, reduction
mammoplasty, augmentation mammoplasty, castration, orchidectomy,
penectomy, vaginoplasty, hysterectomy, salpingectomy,
vaginectomy, oophorectomy and phalloplasty in the absence of any
diagnosable birth defect or other medically defined pathology,
except gender dysphoria, are included in this category labeled
surgical sex reassignment.
Non-Genital surgical sex reassignment refers to any and all other surgical procedures of non-genital, or non-breast sites (nose, throat, chin, cheeks, hips, etc.) conducted for the purpose of effecting a more masculine appearance in a genetic female or for the purpose of effecting a more feminine appearance in a genetic male, in the absence of identifiable pathology which would warrant such surgery regardless of the patient's genetic sex (facial injuries, hermaphroditism, etc.).
3.4 Gender Dysphoria.
Gender Dysphoria herein refers to that psychological state
whereby a person demonstrates dissatisfaction with their sex of
birth and the sex role, as socially defined, which applies to
that sex, and who requests hormonal and surgical sex
reassignment. Gender dysphoria, herein, does not refer to cases
of infant sex reassignment or reannouncement. Gender dysphoria,
therefore, is the primary working diagnosis applied to any and
all persons requesting surgical and hormonal sex reassignment.
3.5 Clinical Behavioral Scientist.
1Possesion of an academic degree in a behavioral science
does not necessarily attest to the possession of sufficient
training or competence to conduct psychotherapy, psychologic
counseling, nor diagnosis of gender identity problems. Persons
recommending sex reassignment surgery or hormone therapy should
have documented training and experience in the diagnosis and
treatment of a broad range of psychologic conditions. Licensure
or certification as a psychological therapist or counselor does
not necessarily attest to competence in sex therapy. Persons
recommending sex reassignment surgery or hormone therapy should
have the documented training and experience to diagnose and treat
a broad range of sexual conditions. Certification in sex therapy
or counseling does not necessarily attest to competence in the
diagnosis and treatment of gender identity conditions or
disorders. Persons recommending sex reassignment surgery or
hormone therapy should have proven competence in general
psychotherapy, sex therapy, and gender counseling/therapy.
Any and all recommendations for sex reassignment surgery and hormone therapy should be made only by clinical behavioral scientists possessing the following minimal documentable credentials and expertise:
3.5.1.
A minimum of a Masters Degree in a clinical behavioral science,
granted by an institution of education accredited by a national
or regional accrediting board.
3.5.2.
One recommendation, of the two required for sex reassignment
surgery, must be made by a person possessing a doctoral degree
(e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.) in a
clinical behavioral science, granted by an institution of
education accredited by a national or regional accrediting board.
3.5.3.
Demonstrated competence in psychotherapy as indicated by a
license to practice medicine, psychology, clinical social work,
marriage and family counseling, or social psychotherapy, etc.,
granted by the state of residence. In states where no such
appropriate license board exists, persons recommending sex
reassignment surgery or hormone therapy should have been
certified by a nationally known and reputable association, based
on education and experience criteria, and, preferably, some form
of testing (and not simply on membership received for dues paid)
as an accredited or certified therapist/counselor (e.g. American
Board of Psychiatry and Neurology, Diploma in Psychology from the
American Board of Professional Psychologists, Certified Clinical
Social Workers, American Association of Marriage and Family
Therapists, American Professional Guidance Association, etc.).
3.5.4.
Demonstrated specialized competence in sex therapy and theory as
indicated by documentable training and supervised clinical
experience in sex therapy (in some states professional licensure
requires training in human sexuality; also, persons should have
approximately the training and experience as required for
certification as a sex Therapist or Sex Counselor by the American
Association of Sex Educators, Counselors and Therapists, or as
required for membership in the Society for Sex Therapy and
Research). Continuing education in human sexuality and sex
therapy should also be demonstrable.
3.5.5.
Demonstrated and specialized competence in therapy, counseling,
and diagnosis of gender identity disorders as documentable by
training and supervised clinical experience, along with
continuing education. The behavioral scientists recommending sex
reassignment surgery and hormone therapy and the physician and
surgeon(s) who accept those recommendations share responsibility
for certifying that the recommendations are made based on
competency indicators as described above.
4.1.1. Principle 1.
Hormonal and surgical sex reassignment is extensive in its
effects, is invasive to the integrity of the human body, has
effects and consequences which are not, or are not readily,
reversible, and may be requested by persons experiencing
short-termed delusions or beliefs which may later be changed and
reversed.
4.1.2. Principle 2
Hormonal and surgical sex reassignment are procedures requiring
justification and are not of such minor consequence as to be
performed on an elective basis.
4.1.3. Principle 3.
Published and unpublished case histories are known in which the
decision to undergo hormonal and surgical sex reassignment was,
after the fact, regretted and the final result of such procedures
proved to be psychologically dehabilitating to the patients.
4.1.4 Standard 1.
2Hormonal and/or surgical sex reassignment on demand
(i.e., justified simply because the patient has requested such
procedures) is contraindicated. It is herein declared to be
professionally improper to conduct, offer, administer or perform
hormonal sex reassignment and/or surgical sex reassignment
without careful evaluation of the patient's reasons for
requesting such services and evaluation of the beliefs and
attitudes upon which such reasons are based.
4.2.1. Principle 4.
The analysis or evaluation of reasons, motives, attitudes,
purposes, etc., requires skills not usually associated with the
professional training of persons other than clinical behavioral
scientists.
4.2.2. Principle 5.
Hormonal and/or surgical sex reassignment is performed for the
purpose of improving the quality of life as subsequently
experienced and such experiences are most properly studied and
evaluated by the clinical behavioral scientist.
4.2.3. Principle 6.
Hormonal and surgical sex reassignment are usually offered to
persons, in part, because a psychiatric/psychologic diagnosis of
transsexualism (see DSM-III, section 302.5x), or some related
diagnosis, has been made. Such diagnoses are properly made only
by clinical behavioral scientists.
4.2.4. Principle 7.
Clinical behavioral scientists, in deciding to make the
recommendation in favor of hormonal and/or surgical sex
reassignment share the moral responsibility for that decision
with the physician and/or surgeon who accepts that
recommendation.
4.2.5. Standard 2.
Hormonal and surgical (genital and breast) sex reassignment must
be preceded by a firm written recommendation for such procedures
made by a clinical behavioral scientist who can justify making
such a recommendation by appeal to training or professional
experience in dealing with sexual disorders, especially the
disorders of gender identity and role.
4.3.1. Principle 8.
The clinical behavior scientist's recommendation for hormonal
and/or surgical sex reassignment should, in part, be based upon
an evaluation of how well the patient fits the diagnostic
criteria for transsexualism as listed in the DSM-III-R category
302.50 to wit:
A. Persistent discomfort and sense of inappropriateness about
one's assigned sex.
B. Persistent preoccupation for at least two years with getting
rid of one's primary and secondary sex characteristics and
acquiring the sex characteristics of the other sex.
C. The patient has reached puberty.
This definition of transsexualism is herein interpreted not to exclude persons who meet the above criteria but who otherwise may, on the basis of their past behavioral histories, be conceptualized and classified as transvestites and/or effeminate male homosexuals or masculine female homosexuals.
4.3.2. Principle 9.
The intersexed patient (with a documented hormonal or genetic
abnormality) should first be treated by procedures commonly
accepted as appropriate for such medical conditions.
4.3.3. Principle 10.
The patient having a psychiatric diagnosis (i.e., schizophrenia)
in addition to a diagnosis of transsexualism should first be
treated by procedures commonly accepted as appropriate for such
non-transsexual psychiatric diagnoses.
4.3.4. Standard 3.
Hormonal and surgical sex reassignment may be made available to
intersexed patients and to patients having non-transsexual
psychiatric/psychologic diagnoses if the patient and therapist
have fulfilled the requirements of the herein listed standards;
if the patient can be reasonably expected to be habilitated or
rehabilitated, in part, by such hormonal and surgical sex
reassignment procedures; and if all other commonly accepted
therapeutic approaches to such intersexed or non-transsexual
psychiatrically/psychologically diagnosed patients have been
either attempted, or considered for use prior to the decision not
to use such alternative therapies. The diagnosis of
schizophrenia, therefore, does not necessarily preclude surgical
and hormonal sex reassignment.
4.4.1. Principle 11.
Hormonal sex reassignment is both therapeutic and diagnostic in
that the patient requesting such therapy either reports
satisfaction or dissatisfaction regarding the results of such
therapy.
4.4.2. Principle 12.
Hormonal sex reassignment may have some irreversible effects
(infertility, hair growth, voice deepening and clitoral
enlargement in the female-to-male patient and infertility and
breast growth in the male-to-female patient) and, therefore, such
therapy must be offered only under guidelines proposed in the
present standards.
4.4.3. Principal 13.
Hormonal sex reassignment should precede surgical sex
reassignment as its effects (Patient satisfaction or
dissatisfaction) may indicate or contraindicate later surgical
sex reassignment.
4.4.4. Standard 4.
3The initiation of hormonal sex reassignment shall be
preceded by recommendation for such hormonal therapy, made by a
clinical behavioral scientist.
4.5.1. Principle 14.
The administration of androgens to females and of estrogens
and/or progesterones to males may lead to mild or serious
health-threatening complications.
4.5.2. Principle 15.
Persons who are in poor physical health, or who have identifiable
abnormalities in blood chemistry, may be at above average risk to
develop complications should they receive hormonal medication.
4.5.3 Standard 5.
The physician prescribing hormonal medication to a person for the
purpose of effecting hormonal sex reassignment must warn the
patient of possible negative complications which may arise and
that physician should also make available to the patient (or
refer the patient to a facility offering) monitoring of relevant
blood chemistries and routine physical examinations including,
but not limited to, the measurement of SGPT in persons receiving
testosterone and the measurement of SGPT, bilirubin,
triglycerides and fasting glucose in persons receiving estrogens.
4.6.1. Principle 16.
The diagnostic evidence for transsexualism (see 4.3.1. above)
requires that the clinical behavioral scientist have knowledge,
independent of the patient's verbal claim, that the dysphoria,
discomfort, sense of inappropriateness and wish to be rid of
one's own genitals, have existed for at least two years. This
evidence may be obtained by interview of the patient's appointed
informant (friend or relative) or it may be obtained by the fact
that the clinical behavioral scientist has professionally known
the patient for an extended period of time.
4.6.2Standard 6.
The clinical behavioral scientist making the recommendation in
favor of hormonal sex reassignment shall have known the patient
in a psychotherapeutic relationship for at least 3 months prior
to making said recommendation.
4.7.1. Principle 17.
Peer review is a commonly accepted procedure in most branches of
science and is used primarily to insure maximal efficiency and
correctness of scientific decisions and procedures.
4.7.2. Principle 18.
Clinical behavioral scientists must often rely on possibly
unreliable or invalid sources of information (patients' verbal
reports or the verbal reports of the patients' families and
friends) in making clinical decisions and in judging whether or
not a patient has fulfilled the requirements of the herein listed
standards.
4.7.3. Principle 19.
Clinical behavioral scientists given the burden of deciding who
to recommend for hormonal and surgical sex reassignment and for
whom to refuse such recommendations are subject to extreme social
pressure and possible manipulation as to create an atmosphere in
which charges of laxity, favoritism, sexism, financial gain,
etc., may be made.
4.7.4 Principle 20.
A plethora of theories exist regarding the etiology of gender
dysphoria and the purposes or goals of hormonal and/or surgical
sex reassignment such that the clinical behavioral scientist
making the decision to recommend such reassignment for a patient
does not enjoy the comfort or security of knowing that his or her
decision would be supported by the majority of his or her peers.
4.7.5. Standard 7.
The clinical behavior scientist recommending that a patient
applicant receive surgical (genital and breast) sex reassignment
must obtain peer review, in the format of a clinical behavioral
scientist peer who will personally examine the patient applicant,
on at least one occasion, and who will, in writing state that he
or she concurs with the decision of the original clinical
behavioral scientist. Peer review (a second opinion) is not
required for hormonal sex reassignment. Non-genital and breast
surgical sex reassignment does not require the recommendation of
a behavioral scientist. At least one of the two behavioral
scientists making the favorable recommendation for surgical
(genital and breast) sex reassignment must be a doctoral level
clinical behavioral scientist.4
4.8.1. Standard 8.
The clinical behavioral scientist making the primary
recommendation in favor of genital (surgical) sex reassignment
shall have known the patient in a psychotherapeutic relationship
for at least 6 months prior to making said recommendation. That
clinical behavioral scientist should have access to the results
of psychometric testing (including IQ testing of the patient)
when such testing is clinically indicated.
4.9.1. Standard 9.
Genital sex reassignment shall be preceded by a period of at
least 12 months during which time the patient lives full time in
the social role of the genetically other sex.
4.10.1. Principle 21.
Genital surgical sex reassignment includes the invasion of, and
the alteration of, the genitourinary tract. Undiagnosed
pre-existing genitourinary disorders may complicate later genital
surgical sex reassignment.
4.10.2. Standard 10.
5Prior to genital surgical sex reassignment a urological
examination should be conducted for the purpose of identifying
and perhaps treating abnormalities of the genitourinary tract.
4.11.1. Standard 11.
The physician administering or performing surgical (genital) sex
reassignment is guilty of professional misconduct if he or she
does not receive written recommendations in favor of such
procedures from at least two clinical behavioral scientists; at
least one of which is a doctoral level clinical behavioral
scientist and one of whom has known the patient in a professional
relationship for at least 6 months.
4.12.1. Principle 22.
The care and treatment of sex reassignment applicants or patients
often causes special problems for the professional offering such
care and treatment. These special problems include, but are not
limited to, the need for the professional to cooperate with
education of the public to justify his or her work, the need to
document the case history perhaps more completely than is
customary in general patient care, the need to respond to
multiple, nonpaying, service applicants and the need to be
receptive and responsible to the extra demands for services and
assistance often made by sex reassignment applicants as compared
to other patient groups.
4.12.2. Principle 23.
Sex reassignment applicants often have need for post-therapy
(psychologic, hormonal and surgical) follow-up care for which
they are unable or unwilling to pay.
4.12.3. Principle 24.
Sex reassignment applicants often are in a financial status which
does not permit them to pay excessive professional fees.
4.12.4. Standard 12.
It is unethical for professionals to charge sex reassignment
applicants "whatever the traffic will bear" or
excessive fees far beyond the normal fees charged for similar
services by the professional. It is permissible to charge sex
reassignment applicants for services in advance of the tendering
of such services even if such an advance fee arrangement is not
typical of the professional's practice. It is permissible to
charge patients, in advance, for expected services such as
post-therapy follow-up care and/or counseling. It is unethical to
charge patients for services which are essentially research and
which services do not directly benefit the patient.
4.13.1. Principle 25.
Sex reassignment applicants often experience social, legal and
financial discrimination not known, at present, to be prohibited
by federal or state law.
4.13.1. Principle 26.
Sex reassignment applicants often must conduct formal ar
semiformal legal proceedings (i.e., in-court appearances against
insurance companies or in pursuit of having legal documents
changed to reflect their new sexual and gender status, etc.).
4.13.3. Principle 27.
Sex reassignment applicants, in pursuit of what are assumed to be
their civil rights as citizens, are often in need of assistance
(in the form of copies of records, letters of endorsement, court
testimony, etc.) from the professionals involved in their case.
4.13.4. Standard 13.
It is permissible for a professional to charge only the normal
fee for services needed by a patient in pursuit of his or her
civil rights. Fees should not be charged for services for which,
for other patient groups, such fees are not normally charged.
4.14.1. Principle 28.
Hormonal and surgical sex reassignment has been demonstrated to
be a rehabilitative or habilitative, experience for properly
selected adult patients.
4.14.2. Principle 29.
Hormonal and surgical sex reassignment are procedures which must
be requested by, and performed only with the agreement of, the
patient having informed consent. Sex reannouncement or sex
reassignment procedures conducted on infantile or early childhood
intersexed patients are common medical practices and are not
included in or affected by the present discussion.
Sex reassignment applicants often, in their pursuit of sex reassignment, believe that hormonal and surgical sex reassignment have fewer risks than such procedures are known to have.
4.14.4. Standard 14.
Hormonal and surgical sex reassignment may be conducted of
administered only to persons obtaining their legal majority (as
defined by state law) or to persons declared by the courts as
legal adults (emancipated minors).
4.15.1. Standard 15.
Hormonal and surgical sex reassignments should be conducted or
administered only after the patient applicant has received full
and complete explanations, preferably in writing, in words
understood by the patient applicant, of all risks inherent in the
requested procedures.
4.16.1. Principle 31.
Gender dysphoric sex reassignment applicants and patients enjoy
the same rights to medical privacy as does any other patient
group.
4.16.2. Standard 16.
The privacy of the medical record of the sex reassignment patient
shall be safeguarded according to procedures in use to safeguard
the privacy of any other patient group.
5.1
Prior to the initiation of hormonal sex reassignment:
5.1.1.
The patient must demonstrate that the sense of discomfort with
the self and the urge to rid the self of the genitalia and the
wish to live in the genetically other sex role have existed for
at least 2 years.
5.1.2.
The patient must be known to a clinical behavioral scientist for
at least 3 months and that clinical behavioral scientist must
endorse the patient's request for hormone therapy.
5.1.3.
Prospective patients should receive a complete physical
examination which includes, but is not limited to, the
measurement of SGPT in persons to receive testosterone and the
measurement of SGPT, bilirubin, triglycerides and fasting glucose
in persons to receive estrogens.
5.2.
Prior to initiation of genital or breast sex reassignment
(Penectomy, orchidectomy, castration, vaginoplasty, mastectomy,
hysterectomy, oophorectomy, salpingectomy, vaginectomy,
phalloplasty, reduction mammoplasty, breast amputation):
5.2.1. See 5.1.1., above.
5.2.2.
The patient must be known to the clinical behavioral scientist
for at least 6 months and that clinical behavioral scientist must
endorse the patient's request for genital surgical reassignment.
5.2.3.
The patient must be evaluated at least once by a clinical
behavioral scientist other than the clinical behavioral scientist
specified in 5.2.2. above and that second clinical behavioral
scientist must endorse the patient's request for genital sex
reassignment. At least one of the clinical behavioral scientists
making the recommendation for genital sex reassignment must be a
doctoral level clinical behavioral scientist.
5.2.4
The patient must have been successfully living in the genetically
other sex role for at least one year.
5.3
During and after services are provided:
5.3.1
The patient's right to privacy should be honored.
5.3.2.
The patient must be charged only appropriate fees and these fees
may be levied in advance of services.
1. The drafts of these Standards of Care dated 2/79 and 1/80 require that all recommendations for hormonal and/or surgical sex reassignment be made by licensed psychologists or psychiatrists. That requirement was rescinded, and replaced by the definition in section 3.5, in 3/81.
2. The present standards provide no guidelines for the granting of non-genital/breast cosmetic or reconstructive surgery. The decision to perform such surgery is left to the patient and surgeon. The original draft of this document did recommend the following however (rescinded 1/80): "Non-genital sex reassignment (facial, hip, limb, etc.) shall be preceded by a period of at least 6 months during which time the patient lives full-time in the social role of the genetically other sex."
3. This standard, in the original draft, recommended that the patient must have lived successfully in the social/gender role of the genetically other sex for at least 3 months prior to the initiation of hormonal sex reassignment. This requirement was rescinded 1/80.
4. In the original and 1/80 version of these standards, one of the clinical behavioral scientists was required to be a psychiatrist. That requirement was rescinded in 3/81.
5. This requirement was rescinded 1/90.
6. DSM-III-R Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised) Washington, D.C. The American Psychiatric Association, 1987.
Original draft dated February 13, 1979
Revised draft (1/80) dated January 20, 1980
Revised draft (3/81) dated March 9, 1981.
Revised draft (1/90) dated January 25, 1990.