Special Features
Glossary
Benjamin Standards Of Care
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annie's place
Special Features
Glossary
Benjamin Standards Of Care
|
The founding committee of the Harry Benjamin International Gender Dysphoria Association, Inc.
Paul A. Walker, Ph.D. (Chairperson)
Jack C. Berger, M.D.
Richard Green, M.D.
Donald R. Laub, M.D.
Charles L. Reynolds, Jr., M.D.
Leo Wollman, M.D.
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 officially. The number of candidates 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 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.
3.2 Hormonal sex reassignment.
3.3 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.
3.5 Clinical Behavioral Scientist.
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.
3.5.2.
3.5.3.
3.5.4.
3.5.5.
4.1.1. Principle 1.
4.1.2. Principle 2
4.1.3. Principle 3.
4.1.4 Standard 1.
4.2.1. Principle 4.
4.2.2. Principle 5.
4.2.3. Principle 6.
4.2.4. Principle 7.
4.2.5. Standard 2.
4.3.1. Principle 8.
A. Persistent discomfort and sense of inappropriateness about
one's assigned sex.
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.
4.3.3. Principle 10.
4.3.4. Standard 3.
4.4.1. Principle 11.
4.4.2. Principle 12.
4.4.3. Principal 13.
4.4.4. Standard 4.
4.5.1. Principle 14.
4.5.2. Principle 15.
4.5.3 Standard 5.
4.6.1. Principle 16.
4.6.2Standard 6.
2. Statement of Purpose
3. Definitions
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.
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.)
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.
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.
1
Possesion 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.
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.
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.
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.).
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.
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. Principles and Standards
Introduction
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.
Hormonal and surgical sex reassignment are procedures requiring justification
and are not of such minor consequence as to be performed on an elective
basis.
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.
2
Hormonal 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.
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.
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.
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.
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.
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.
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:
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.
The intersexed patient (with a documented hormonal or genetic
abnormality) should first be treated by procedures commonly accepted as
appropriate for such medical conditions.
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.
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 therapeutica pproaches 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.
HORMONAL SEX REASSIGNMENT
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.
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.
Hormonal sex reassignment should precede surgical sex reassignment as
its effects (Patient satisfaction or dissatisfaction) may indicate or
contraindicate later surgical sex reassignment.
3
The initiation of hormonal sex reassignment shall be preceded
by recommendation for such hormonal therapy, made by a clinical
behavioral scientist.
The administration of androgens to females and of estrogens and/or
progesterones to males may lead to mild or serious health-threatening
complications.
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.
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.
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.
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.
5
Prior 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.
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.
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