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The Hormonal and Surgical Sex Reassignment
of Gender Dysphoric Persons
Original draft prepared by: The founding committee of the Harry
Benjamin International Gender
Dysphoria Association, Inc.
Paul A. Walker, PhD (chairperson)
Jack C. Berger, MD
Richard Green, MD
Donald R. Laub, MD
Charles L. Reynolds, Jr., MD
Leo Wollman, MD
Original draft approved by: The attendees of the Sixth Inter-
national Gender Dysporia 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. (1/80)
Revised draft (3/81) approved by: The majority of the membership of the
Harry Benjamin International Gender
Dysphoria Association, Inc. (3/81)
Revised draft (1/90) approved by: The majority of the membership of the
Harry Benjamin International Gender
Dysphoria Association, Inc. (1/90)
Distributed by: The Harry Benjamin International
Gender Dysphoria Association, Inc.
1515 El Camino Real
Palo Alto, California 94306
Standards of Care: The Hormonal and Surgical
Sex Reassignment of Gender Dysphoric Persons
1. Introduction
As of the beginning of 1979, and 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 U.S.A. citizens consider themselves to be valid candidates
for sex reassignment. World estimates are not available. As of mid-1978,
approximately 40 centersin the Western hemisphere offered surgical sex
reassignment to persons haveing 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 pssible psychologic, 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 indentified as experts on
the topic of gender identity. However, until the present, no statement
of the standard of care to be offered to dysphoric patients (sex
reassignment applicants) has receieved official sanction by any
indentifiable professional group. The present document is designed to
fill that void.
2. Statement of Purpose
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. Definitions
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 of
gender identity recommend that the time parameters listed below 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 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 esx 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.* Possession 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 to diagnose
and treat a broad range of sexual conditions. Certification in sex
therapy or counseling does not necessarily attest to competence in the
diagnossis 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 recomendations for sex reassignment surgery and hormone
therapy should be made only by clinical behavioral scientists possessing
the foloowing minimal documentable credentials and expertise:
3.5.1 A minimum of a Masters Degree in a clinical behavior 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, psychotherapy, clinical social work, marriage and
family counseling, or sociasl 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 cretified by a nationally known and reputable association,
based on education and experience criteria and, preferably, some form of
testing (and not simply on membership recieved for dues paid) as an
accredited or certified therapist/counselor (e.g. American Board of
Psychiatry and Neurology, Diplomate 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 idenity 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 the responsibilty for certifying that the
recommendations are made based on competency indicators as described
above.
_____________________________
* The drafts of these Standards of Care date 2/79 and 1/80 reuire that
all recommendations for hormonal and/or surgical sex reassignment be
made by licensed psychologists or psychiatrists. That requirement was
rescinded, and replace by the definition in section 3.5, in 3/81.
_____________________________
4. Principals and Standards
Introduction
4.1.1 Principal 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 Principal 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 Principal 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. Hormonal and/or surgical* sex reassignment on demand
(i.e., justified simply because the patient has requested such
procedures) is contraindicated. It is herein delcared 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 Principal 4. The analysis or evaluation of reasons, motives,
attitudes, puposes, etc., requires skills not usually associated with
the professional training of persons other tahn clinical behavioral
scientists.
4.2.2 Principal 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 Principal 6. Hormonal and surgical sex reassignment are usually
offered to persons, in part, because a psychiatric/psychologic diagnosis
of transsexualism (see DSM-II, section 302.5X), or some related
diagnosis, has been made. Such diagnoses are properly made only by
clinical behavioral scientists.
4.2.4 Principal 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 made by a firm written recommendation for such
procedures made by 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 Principal 8. The clinical behavioral scientist's recommendation
for hormonal and/or surgical sex reassignment should, in part, be based
upon and evaluation of how well the patient fits the diagnostic criteria
for transsexualism as listed in the DSM-III-R category 302.50 to wit:[1]
"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 person has reached puberty."
This definition of transsexualism is herein interpreted not to excluded
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 Principal 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 Principal 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/psychological 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.
_____________________________
* 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
proceeded 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."
_____________________________
Hormonal Sex Reassignment
4.4.1 Principal 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 Principal 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 the guidelines proposed in the
present standards.
4.4.3 Principal 13. Hormonal sex reassignment should proceed surgical
sex reassignment as its effects (Patient satisfaction or
dissatisfaction) may indicate on contraindicate later surgical sex
reassignment.
4.4.4 Standard 4.* The initiation of hormonal sex reassignment shall
be proceeded by recommendation for such hormonal therapy made by a
clinical behavioral scientist.
4.5.1 Principal 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 Principal 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 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 Principal 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 best be obtained by the fact that the
clinical behavioral scientist has professionally know the patient for an
extended period of time.
_____________________________
* 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.
_____________________________
Surgical (Genital and/or Breast) Sex Reassignment
4.7.1 Principal 17. Peer review is a commonly accepted procedure in
most branches of science and is used primarily to ensure maximal
efficiency and correctness of scientific decisions and procedures.
4.7.2 Principal 18. Clinical behavioral scientists must often rely on
possibly unreliable or invalid sources of information (patient's verbal
reports or the verbal reports of the patient's 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 Principal 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 Principal 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.
4.7.8 Standard 7. The clinical behavioral scientist recommending that
a patient 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) in not required for hormonal sex reassignment.
Non-genital/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.*
4.8.1 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 a 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 proceeded 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 Principal 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.** 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.
_____________________________
* 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.
** This requirement was rescinded 1/90.
_____________________________
Miscellaneous
4.12.1 Principal 22. The care and treatment of sex reassignment
applicants or patients often causes special problems for the
professionals offering such care and treatment. These special problems
include, but are not limited to, the need for the professional to
cooperate with the 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
responsive to the extra demands for services and assistance often made
by sex reassignment applicants as compared to other patient groups.
4.12.2 Principal 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 Principal 24. Sex reassignment applicants are often 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 changed 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 Principal 25. Sex reassignment applicants often experience
social, legal and financial discrimination not known, at present, to be
prohibited by federal or state law.
4.13.2 Principal 26. Sex reassignment applicants often must conduct
formal or 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 genderal status, etc.).
4.13.3 Principal 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 change only
the normal fee for services needed by a patient in pursuit of his or her
civil rights. Fees should not be changed for services for which, for
other patient groups, such fees are not normally charged.
4.14.1 Principal 28. Hormonal and surgical sex reassignment has been
demonstrated to be a rehabilitative, or habilitative, experience for
properly selected adult patients.
4.14.2 Principal 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 discussions.
4.14.3 Principal 30. 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 or 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).
5.15.1 Standard 15. Hormonal and surgical sex reassignment may be
conducted or administer only after the patient 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 Principal 31. Gender dysphoric sex reassignment applicants and
patients enjoy the same rights to medical preivacy 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 the procedures in
use to safeguard the privacy of any other patient group.
5. Explication
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 the 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 a clinical behavioral scientist for
at least 3 months and that clinical behavioral scientist must endorse
the patient's request for genital surgical sex 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 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
my be levied in advance of services.
_____________________________
[1] 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
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