Harry Benjamin Standards of Care for Gender Dysphoric
Persons
Revised Draft (1/90)
STANDARDS OF CARE
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, 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.
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. (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, 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 U.S.A. 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 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
identified 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
received official sanction by any identifiable 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
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 be doubled, or
tripled. It is recommended that the reasons for any exceptions
to these standards, in the management of any individual case,
be 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
sex in persons diagnosed as gender dysphoric. Such surgical
procedures as mastectomy, reduction mammoplasty, augmentation
mammoplasty, castration, orchiectomy, 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_.
[1] 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 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, psychotherapy, 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, 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 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 the responsibility for
certifying that the recommendations are made based on
competency indicators as described above.
4. Principles and Standards
_Introduction_
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. Hormonal and/or surgical[2] 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 made 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 behavioral 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:[3]
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
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/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.
_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 the guidelines proposed in the present
standards.
4.4.3 Principle 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.[4] The 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 best be obtained by the fact that the clinical
behavioral scientist has professionally known the patient
for an extended period of time.
_Surgical (Genital and/or Breast) Sex Reassignment_
4.7.1 Principle 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 Principle 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 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.
4.7.8 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) is
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.[5]
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.[6] 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.
_Miscellaneous_
4.12.1 Principle 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 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 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 Principle 25. Sex reassignment applicants often
experience social, legal and financial discrimination not
known, at present, to be prohibited by federal or state
law.
4.13.2 Principle 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 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 discussions.
4.14.3 Principle 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).
4.15.1 Standard 15. Hormonal and surgical sex reassignment may
be conducted or administered 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 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 records 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, orchiectomy, 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 may be levied in advance of services.
Notes:
[1] The drafts of these Standards of Care dated 2/79 and 1/80
required 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] _DSM-III-R Diagnostic and Statistical Manual of Mental
Disorders_ (Third Edition-Revised). Washington, D.C. The
American Psychiatric Association, 1987.
[4] 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.
[5] 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.
[6] This requirement was rescinded 1/90.
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