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The Harry Benjamin Standards of Care is a consensus opinion on trnassexual treatment by (presumably) medical and psychological experts. There have been five versions, published in 1979, 1980, 1981, 1990, and 1998. Below you will find the 1990 version (with slight, mainly formatting, modifications).
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 InternationalGender Dysphoria Association, Inc.
Revised draft (1/90) approved by: The majority of the membership of the Harry Benjamin InternationalGender 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.
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