Gender Identity Disorder Information

A Critical Examination of Selected Issues from the

Many people with GID take issue with the accepted Standards of Care. They believe the Standards are unnecessarily restrictive and are based on a faulty premise. That faulty premise being that the individuals in question are not capable of making decisions for themselves. Furthermore, that there is an undercurrent in the Standards of Care that seems to suggest a need for as many opportunities as possible for the individual to "back out" of transition - presumably when the person "comes to their senses." The preferred Triadic Therapy outlined by these Standards also, if rigidly adhered to, may make transition from one gender to another unnecessarily difficult and virtually sets up the patient for failure.

III. Diagnostic Nomenclature

{excerpt]The purpose of the DSM-IV and ICD-10 is to guide treatment and research. Different professional groups created these nomenclatures through consensus processes at different times. There is an expectation that the differences between the systems will be eliminated in the future. At this point, the specific diagnoses are based more on clinical reasoning than on scientific investigation.

One of the main criticisms of the HBSOC is that it continues errors and contradictions presented in the DSM and ICD manuals. Under the DSM-IV, these diagnoses require evidence of distress or impairment in functioning. Functional impairment that is solely due to societal prejudice based on perceived social deviance does not meet this criterion. So, under the DSM-IV, being transgender does not in itself constitute a mental disorder. By saying that these criteria are based on "clinical reasoning" rather than empirical evidence is a clever way of saying they "made it up." There are many who argue that Gender Identity Dysphoria no more meets the criteria for inclusion than Homosexuality did, which was declassified as a "mental illness" in 1973. Others argue such a removal was purely an act of "Political Correctness." However, inclusion was most probably an act of "Political Prejudice" which mirrored the popular prejudices against gays.

Are Gender Identity Disorders Mental Disorders? To qualify as a mental disorder, a behavioral pattern must result in a significant adaptive disadvantage to the person and cause personal mental suffering. The DSM-IV and ICD-10 have defined hundreds of mental disorders which vary in onset, duration, pathogenesis, functional disability, and treatability. The designation of gender identity disorders as mental disorders is not a license for stigmatization, or for the deprivation of gender patients' civil rights. The use of a formal diagnosis is often important in offering relief, providing health insurance coverage, and guiding research to provide more effective future treatments.

As mentioned, the DSM-IV contradicts itself where gender diagnosis is concerned. In the introduction to the manual it states,

"Neither deviant behavior, nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual."

This statement is at odds with what it says in the section on Gender Identity Dysphoria:

"Gender Identity Disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities."

The earlier statement in the manual essentially says that, if the patient is biologically male, but presents himself as female or engages in feminine behaviors, AND doing so causes social conflicts where SOCIETY doesn't accept the behavior, such behavior is NOT a "mental disorder" because SOCIETY is the "person" with the problem. However, the section on Gender Disorders says that if the person pushes it "too far" (with no solid definition of where the line is drawn), then the person DOES have a "mental disorder" EVEN if the person is totally okay with the behavior and endures or tolerates the social conflict it creates (in other words, is "well adjusted"). The diagnostic manual creates a contradictory exception based on the therapist's subjective ideological perceptions of what is "appropriate social behavior," rather than on the patient's ACTUAL ability to cope with or accept social pressures or prejudices with regard to their preferred behavior or presentation. So where is that "line in the sand" that makes the behavior more than "nonconformist?" And how can the SAME BEHAVIOR be "society's problem" under one definition and the "patient's problem" under the other? The simple answer is that it CAN'T.

This begs the question: if the Harry Benjamin Association's own Standards acknowledge that it is NOT a "mental illness" then why do they require, as step number one, a consultation with a mental health professional? Critics of the Standards charge that this makes no logical sense. If the "significant adaptive disadvantage" is that the person is physically and socially the wrong sex, then correcting their phenotypical SEX - their apparent physical being - will provide the "adaptive advantage." Furthermore, most third party insurance companies refuse to cover ANY services related to Gender Identity Dysphoria and many psychotherapists tell insurers they are treating the patients for "depression" instead of Gender Dysphoria. Furthermore, the American Psychiatric Association's maintainence of Gender Identity Dysphoria among "Paraphilias" in the DSM-IV essentially IS the license for stigmatization. Especially "Transvestic Fetishism" which is placed in a list that includes "Pedophilia," thus encouraging and legitimizing unfounded beliefs that transgender behaviors are equivalent, even criminal, "sexual perversions." Inclusion isn't a necessity to ensure insurance coverage if the insurers purposely exclude such treatment or the therapists are lying to the insurers about the nature of the therapy to receive payments under a therapy which IS covered. If statistics are correct, "transgender" activities and beliefs are so prevalent as to be considered a normal diversification of the human condition, rather than a deviance from the norm. In short, there appears to be little logical or empirical reason to include transgender behaviors in a list of mental illnesses.

Recently, surveys have found that a large portion of the American population are currently, or have been, mentally ill. A report in 1993 by the National Institute of Mental Health stated that 28% of the population (52 MILLION people!) were suffering from a DIAGNOSABLE "mental disorder" over the year. A study in 1994 called the "National Comorbidity Study" found a similar percentage (30%) and went on to say one out of every two Americans has experienced a mental disorder at some point in life! The analogy was this: were you to meet someone who claimed every second or third person they met was "crazy," you'd be more inclined to think THEY were the crazy one. Cultural biases play a HUGE role in diagnosis. American psychiatrists are twice as likely to diagnose "schizophrenia" than British psychiatrists. If you hold religious beliefs that are unconventional you are more likely to be labeled "crazy." Poor people are more likely to be "mentally ill" while wealthy people are "eccentric." Ideology tends to guide mental health diagnosis more than widely accepted medical criteria. (reference: Alexander Kealey, Ph.D., "Where's the Line Between Mental Health and Illness?")

VI. Psychotherapy with Adults

{excerpt}Not every adult gender patient requires psychotherapy in order to proceed with hormone therapy, the real life experience, hormones, or surgery.

Again, if the Harry Benjamin Association acknowledges this to be true, why REQUIRE consultation with a therapist as the first step at all? If a person chooses to proceed with transition and runs into emotional road-blocks or other mental health issues, THEN would be the time to seek counsel. There appears to be an underlying assumption that ANYONE who would consider transition from one gender to another MUST need to be evaluated mentally before they take any actions whatsoever. While it says they may not require THERAPY, these Standards still insist on an initial consultation, evaluation, and ultimately require an APPROVAL by the therapist (whether therapy was deemed necessary or not) to proceed. Many transgendered people find this insulting in the extreme. The assumption seems to be that the individual is MENTALLY INCAPABLE (whether therapy was deemed necessary or not) of making a decision concerning a largely cosmetic alteration to their own body.

Furthermore, one scientific study has shown that ". .many, if not most, of the transgendered patients seen for gender services may not require psychological services, a finding established in 1994 after the three year Boulton and Park survey (n=934) of non-clinical transgenders." (source: ICTLEP Standards of Care)

VII. Requirements for Hormone Therapy for Adults

Reasons for Hormone Therapy. . .Hormones are often medically necessary for successful living in the new gender. They improve the quality of life and limit psychiatric co-morbidity, which often accompanies lack of treatment. When physicians administer [hormones], patients feel and appear more like members of their preferred gender.

This being said, many therapists prefer a Triadic Therapy that places the Real Life Experience ahead of eligibility for hormones. So, even though they totally acknowledge that hormones alone MIGHT satisfy the patient's crossgender needs, they will require the individual to attempt to cross live first. Even though they acknowledge that patients will "feel and appear more like members of their preferred gender" (strongly implying that hormones will AID the transsexual's ability to PASS as their preferred gender), many therapists will require the person attempt to cross-live and PASS without their benefit. This seems to critics of the Standards like a ploy used to set up less than passable transsexuals for failure in the early stages of their Real Life Experience. It may explain the unusually high "drop out" rates reported by some Gender Clinics. The argument therefore is that withholding hormones is of no benefit to the transsexual, and may indeed be the ONLY thing some people with GID require to feel comfortable with themselves.

Eligibility Criteria. The administration of hormones is not to be lightly undertaken because of their medical and social risks. Three criteria exist.

1. Age 18 years;

2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks;

3. Either:
a. A documented real life experience of at least three months prior to the administration of hormones; or
b. A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months).

In selected circumstances, it can be acceptable to provide hormones to patients who have not fulfilled criterion 3 - for example, to facilitate the provision of monitored therapy using hormones of known quality, as an alternative to black-market or unsupervised hormone use.

Many transsexuals insist they were aware of their gender difference from an age well before 18 years old. They argue that the effectiveness of hormone treatment is significantly more satisfactory for those who have had HRT before age 18. Secondly, even Endocrinologists don't completely know what all hormones DO or how they interact. Thirdly, there's criteria number "3" which states that the person must either have already started cross-living (without the acknowledged benefits hormones would provide them in passing), or must have undergone a period of psychotherapy (preferably 3 months), even though the Standards previously state that NO psychotherapy may be needed, thus forcing the transsexual individual who was otherwise well adjusted, and did NOT require psychotherapy, to cross-live without benefit or aid of hormones. Granted, it says "of a duration specified by the mental health professional," which COULD be "none," but critics aregue that realistically, how many psychotherapists in private practice are going to tell a client they don't NEED therapy? Their livelihood relies on getting "paying customers" on the couch for sessions! As already mentioned, especially in the United States, clinicians are quick to diagnose "mental illness" for otherwise normative behaviors (there are almost 400 "illnesses" defined in the DSM-IV manual). So, even if the "psychotherapy" isn't aimed at gender issues, critics say you can rest assured that a therapist will find SOMETHING else to diagnose and "treat."

If neither of those scenarios occur, the patient may illegally obtain and self-medicate with hormones in an attempt to FORCE the doctor's hand under the exception for unsupervised hormone use. The Standards later state that it is "ethical" for a therapist to terminate treatment of anyone who refuses to "get with the program." This essentially means that a therapist who insisted that the patient STOP taking black-market hormones, but would hold the patient to the other criteria for hormone eligibility, would be justified in terminating treatment altogether if the patient continued to use black-market hormones when the doctor refused to provide a legitimate prescription. This leaves it entirely up to the subjectivity of the therapist to interpret "do no harm." The argument states that foregoing psychotherapy or foregoing requirements that the patient walk in public in a dress first are MUCH less dangerous to the patient's health than cutting them loose and letting them continue to self-medicate unsupervised with hormones of questionable quality and origin.

Can Hormones Be Given To Those Who Do Not Want Surgery or a Real-life Experience? Yes, but after diagnosis and psychotherapy with a qualified mental health professional following minimal standards. Hormone therapy can provide significant comfort to gender patients who do not wish to cross live or undergo surgery, or who are unable to do so. In some patients, hormone therapy alone may provide sufficient symptomatic relief to obviate the need for cross living or surgery.

This goes back to one of the first statements in the section. A GOOD therapist would do the therapy first and try to determine if hormone administration ALONE would lead to satisfactory comfort for the patient. But a S.O.B. of a therapist, or one that insists the Triadic Sequence be followed in a specific way regardless of individual patient concerns or needs, might require this patient to cross-live FIRST. Critics claim that the LEAST invasive or disruptive therapeutic treatment should always be tried FIRST. Not all therapists tailor the Standards or the Sequence to the individual - which is BAD medicine and certainly not beneficial to the well-being of the patient.

IX. The Real-life Experience

The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one's gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences with their patients. Change of gender role and presentation can be a factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real-life experiences. However, not all changes are negative.

The over-arching tone of this passage is that the Real Life Experience (RLE) is "essential" and that it will threaten the person's employment, personal relationships, and civil rights. First of all, there is NO empirical evidence that the RLE is "essential." It is a "tradition" of the HBSOC. No formal studies have been done to bolster the claim that the RLE is "essential." Informal surveys of post-transition transsexuals who either had a short, or no RLE, seem to indicate that the truncated or absent RLE was not a factor in successful transition from one gender to another. Many people argue that the RLE does not teach the individual how to socially interact as a "woman" (in the case of Male-to-Female Transsexuals), and that it only teaches them how to socially interact as an "outted Transsexual."

Given the acknowledged probability of NEGATIVE social reaction to engaging in the RLE, it seems irresponsible of the HBSOC to recommend it, especially in cases where it is required before HRT for those patients who may have been satisfied with nothing MORE than HRT.

Parameters of the Real-life Experience. When clinicians assess the quality of a person's real-life experience in the desired gender, the following abilities are reviewed:

1) To maintain full or part-time employment;

2) To function as a student;

3) To function in community-based volunteer activity;

4) To undertake some combination of items 1-3;

5) To acquire a (legal) gender-identity-appropriate first name;

6) To provide documentation that persons other than the therapist know that the patient functions in the desired gender role.

Many GID patiens point out that the parameters listed above should be a good indicator as to the INVALIDITY of the Real Life Experience. There are biological females who couldn't meet all the requirements! Consider a woman who doesn't work or go to school, isn't a volunteer in her community, was given a typically male name, maintains a "butch" appearance, and does not engage in stereotypically female activities. Even though she is biologically female, she wouldn't be able to meet the criteria of the RLE for BEING a woman. The ambiguous wording leads to a couple of questions - what is a "gender-identity-appropriate first name?" or "functioning in the desired gender role?" These parameters perpetuate stereotypical beliefs about what is "appropriate" gender-based behavior, even though people whose biological sex is not in question may not meet the criteria. This places an unrealistic and unfair "burden of proof" on the patient to act in a manner which is not necessarily "natural." This is often viewed as insulting as when a normal male is told to "be a man."

Real-life Experience versus Real-life Test. Although professionals may recommend living in the desired gender, the decision as to when and how to begin the real-life experience remains the person's responsibility. Some begin the real-life experience and decide that this often imagined life direction is not in their best interest. Professionals sometimes construe the real-life experience as the real-life test of the ultimate diagnosis. If patients prosper in the preferred gender, they are confirmed as "transsexual," but if they decided against continuing, they "must not have been." This reasoning is a confusion of the forces that enable successful adaptation with the presence of a gender identity disorder. The real-life experience tests the person's resolve, the capacity to function in the preferred gender, and the adequacy of social, economic, and psychological supports. It assists both the patient and the mental health professional in their judgments about how to proceed. Diagnosis, although always open for reconsideration, precedes a recommendation for patients to embark on the real-life experience. When the patient is successful in the real-life experience, both the mental health professional and the patient gain confidence about undertaking further steps.

Whether you call it a Real Life Experience or a Real Life Test, here are some reasons for believing that making RLE/RLT a requirement is irresponsible and potentially damaging to the Transsexual patient:

1) There are genetic women who are unhappy with social expectations and treatment of them. If a TS is dissatisfied with living in a "female social role" it would not necessarily be indicative that her convictions about her gender identity were false.

2) The RLE seems to assume the individual in question is making a mistake they will later regret, and therefore needs an "escape clause" when they "come to their senses and stop all this nonsense." This echoes another assumption: That being transsexual is a CHOICE.

3) Many transsexual people have serious self-esteem issues and don't believe in their own ability to succeed. Providing an "escape clause" in the RLE can create a tempting "easy out" for a transsexual who is unsure of his or her ability to successfully transition.

4) Therapists who rigidly adhere to the Triadic Sequence of Therapy outlined in the Harry Benjamin Standards may, therefore, be setting up some of their patients for failure with the RLE. If a male to female transsexual, for example, isn't very passable, she is forced to "come out" in her personal and professional life, change legal documentation, and live 24/7 as a woman for three months BEFORE getting hormones, when it is well acknowledged that the effects of hormones will aid her in acheiving a more acceptable female appearance. Granted, many therapists do not require the person to be "out" or living in role to get hormones, but SOME do, and for their less-than-passable transsexual patients the RLE might be a "test" they cannot pass.

5) "Backing out" and returning to the old MALE life isn't really possible. Returning to A male life might be, but returning to a previous male life isn't. The RLE means the person has been forced "out" to everyone they know, many old ties and bonds have been permanently severed. A few of those who rejected the person for being transgendered might welcome them back if they "come to their senses" but the relationships will never be the same. The reputation of the person will never be the same again. Arguably, returning to a male existence after trying the RLE can be fraught with as many rejections, social stigmas, and prejudices as going through with transition.

For those who DO continue with their transition, they are not exactly "women" in any legal or social sense. This can, at the very least, lead to awkward social situations - especially of an intimate nature, and a plethora of other issues with employers, hospitals, businesses, and law enforcement. Forcing the patient to live AS a woman before they ARE physically female puts the patient in the middle of a number of potentially awkward or even dangerous social considerations which will, in turn, produce a source of undo anxiety.

6 ) The RLE is actually ILLEGAL in many places. There are many places around the world that STILL have laws on the books making it illegal for a man to dress publicly as a woman. Even more places still say it is illegal for a man to use a public women's rest room. Notes from a therapist don't hold much weight in such matters.

7) In some municipalities changing legal documents for RLE may require the individual to commit perjury. For example, they go to get an official identification card or drivers license changed. They've legally changed their name in the courts, but cannot legally change genders until they've had SRS. They go to the DMV and check the "F" box next to sex. The fine print on the form says something to the effect that they "confirm all answers to be truth under penalty of perjury." Technically and legally speaking, they just LIED on the form and could be prosecuted for it.

X. Surgery

. . . .Sex reassignment is not "experimental," "investigational," "elective," "cosmetic," or optional in any meaningful sense. It constitutes very effective and appropriate treatment for transsexualism or profound GID.

Many are dubious of this statement of the HBSOC in particular. It was included as a way for the Harry Benjamin association to affirm their belief that sex reassignment surgery is "medically necessary" in the hopes of convincing private insurers to cover the procedures. Private insurance companies, and even many surgeons, do not agree that it is "medically necessary." Even many transsexuals do not agree that sex reassignment is "necessary." Statistically, most transsexuals (even those with their letters of recommendation) NEVER get sex reassignment surgery, yet in all other respects they live, love, work, and are otherwise socially adjusted into their preferred gender role. . .in other words they have "successfully transitioned." If the majority of transsexuals can successfully switch gender roles WITHOUT undergoing sex reassignment surgery, it cannot logically be "medically necessary" as part of the treatment. However, apparently no studies have been done to determine WHY the majority of transsexuals never go through with sex reassignment surgery. Are these women not getting surgery because of cost? Because they aren't convinced it will produce adequate results? Fear of surgical complications? Because it would change their relationship with their significant other? Waiting in hopes a better surgical procedure is developed? Or is it simply that sex reassignment surgery ISN'T "medically necessary" for them to be happy?

XII. Genital Surgery

Can Surgery Be Provided Without Hormones and the Real-life Experience?

{excerpt}Genital surgery is not a right that must be granted upon request.

This is often perceived by transgendered people as one of the most arrogant and condescending statements in the whole HBSOC. It also specifically prohibits sex reassignment surgery from being undertaken BEFORE living in the preferred gender role.

Critics charge that the arrogant attitude is indicative of the "history" of the association itself. Until very recently, transgender persons had little influence on the guidelines that would govern their treatment. It is noteworthy that, now that there is a transgender "voice" within the association, the guidelines are more lenient than ever before. However, they still seem very much rooted in the misunderstandings and prejudices of the predominantly male authors of the original Standards of Care. Many people with Gender Dysphoria say they do not believe, even as "experts," these doctors can truly understand the nature of the problem. For example, the restrictions the HBSOC places on access to sex reassignment surgery seem to be rooted in a false belief that the transsexual who seeks such surgery places similar "value" on his/her genetalia as other people of their biological sex, when most of those who seek surgery feel, instead, that their birth sex organs are a deformity and place little, if any, "value" on them. For biological males who do not suffer gender dysphoria, it may be impossible for them to TRULY understand a Male-To-Female Transsexual's dislike of her "male equipment." It is true, that for some, the imperative to procreate is still strong, and if it were medically possible, they would like to BEAR children. Failing that, they have to settle for banking sperm and hoping they might be able to gain a geneticly related child through surrogate means. For older transsexuals, they often already have TRIED to live normal male lives and have already fathered children of their own. The general desire of most people to procreate, though, should have NO bearing on an individual's desire to have their reproductive organs removed or altered.

Another considered point of "arrogance" is the insinuation that any medical professionals who do NOT follow the guidelines of the HBSOC are unethical or, at the very least, less than professional. Supporters of the HBSOC often imply that anyone who didn't follow the guidelines was providing "substandard care." Such statements do not take into account the skills of the medical professional, nor do such statements address what are largely reported to be POSITIVE outcomes. In that respect, the HBSOC is more of a "philosophy of treatment," and those who BELIEVE in it will defend it, and anyone who doesn't follow their philosophy is painted as some kind of "heretical incompetent." One impression of the HBSOC was that the guidelines were more for the MEDICAL people basking in their own "ethics" and "morality" (in protecting these poor confused souls from themselves and what will OBVIOUSLY be a regretable mistake), than concern about whether or not the guidelines were actually beneficial to the success of the TRANSSEXUAL in transitioning. Critics argue that the transsexual patient needs protection, not from himself/herself, but from the negative social ramifications often associated with the process of gender transition - a process CREATED and defined by the Harry Benjamin Standards of Care.

Conditions under which Surgery May Occur.

{excerpt} Typical elective procedures only involve a private mutually consenting contract between a patient and a surgeon. Genital surgeries for individuals diagnosed as having GID are to be undertaken only after a comprehensive evaluation by a qualified mental health professional. Genital surgery may be performed once written documentation that a comprehensive evaluation has occurred and that the person has met the eligibility and readiness criteria. By following this procedure, the mental health professional, the surgeon and the patient share responsibility of the decision to make irreversible changes to the body.

This appears to continue an underlying assumption that the individual is not MENTALLY COMPETENT to make such a decision on his or her own. As they point out, "typical elective procedures only involve a private mutually consenting contract between a patient and a surgeon." So why is sex reassignment treated any differently? Because the HBSOC has already stated that they believe sex reassignment surgery IS NOT an "elective" or "cosmetic" procedure. The HBSOC assertion that sex reassignment surgery is "medically necessary," though, doesn't hold up under scrutiny. Ergo, the procedure actually IS "elective" (since most transsexuals choose NOT to undergo it) and, as it can't produce ACTUAL opposite-sex reproductive organs - only the external APPEARANCE of them - it IS "cosmetic."

If SRS truly is a "medically unnecessary, elective, cosmetic procedure," critics argue requests for it should not be treated any differently than requests for other such procedures, like rhinoplasty, "face lifts," breast augmentation, or any of a host of cosmetic surgical options which aim to improve a person's self-image. The assertion that it requires special consideration because it is "irreversible" is not enough to justify such special consideration either. There are many medical procedures that are irreversible. Specifically related to sex reassignment would be Orchidectomy, the surgical excision of the testicles. This procedure WILL be performed on demand, without the approval of a mental health professional, by many surgeons throughout the world, and it is just as irreversible as sex reassignment surgery. In fact, it's HALF the sex reassignment operation!

It is also not entirely true that sex reassignment is completely irreversible. There have been patients who have transitioned BACK to their birth sex. Granted, modern surgical procedures are often less than satisfactory in producing a pseudo-phallus than in producing a pseudo-vagina, however the point is that people HAVE actually switched back. If the concerns over irreversibility are centered on the topic of reproduction, most transsexual patients will have been rendered sterile by hormone use or orchidectomy prior to sex reassignment anyway. Thus, the irreversability of sterilization should not be the factor that warrants sex reassignment "special consideration."

This "special consideration" appears to be founded in that same underlying current in the HBSOC that the individual is ACTUALLY making a big mistake, and there have to be as many checks, balances, ROADBLOCKS, and "escape clauses" as possible to prevent the person from getting what the HBSOC itself describes as a "medically necessary," "effective and appropriate treatment." Which begs the question: What is the benefit to those who WANT sex reassignment in making access to the procedure unnecessarily difficult?

Other elective, cosmetic procedures do not require the APPROVAL of even one, much less TWO, mental health professionals. Some argue that it is a "confirmation" not "permission" that is provided by the therapists. However, surgery under the HBSOC guidelines CAN NOT occur without the "letters of recommendation." This is APPROVAL and PERMISSION. Again, the HBSOC by it's actions seems to indicate an underlying belief that the patients are not mentally capable of making such a decision on their own, and control over one's own body is surrendered to someone else's judgment. In many ways, transsexuals find themselves in a similar position as women who are legally barred from getting an abortion, in that an outside authority has decided it can limit the autonomy and self-determination of otherwise competent people where their individual biology is concerned. Most opponents to the HBSOC no more want the Harry Benjamin Association to determine what they can do with their own body than most women want the government to regulate theirs.

Some backers of the HBSOC argue that the mental health professional's assessment is needed because the surgeons are specialists in SURGERY, not in mental health. This may be true, but any surgeon interviewing someone who requests such a procedure should be able to gauge whether the person is mentally competent. If the surgeon questions the competency or motives of the person, they should request a consultation or a referral be made to a mental health caregiver. If the DSM-IV asserts that merely BEING transgender does not make a person mentally ill, the act of requesting sex reassignment surgery should not be considered an indication that the person is mentally ill either. If the person's self identity is as the opposite of their biological sex, requesting a surgical correction to their physical nature would be quite RATIONAL.

Some comments on "Sex Reassignment, Harry Benjamin, and some European Roots" By Friedemann Pfaefflin, M.D.

(This paper documents the author's Presidential Address at the XV Harry Benjamin International Gender Dysphoria Symposium, Vancouver, Canada, 7.-18. Sept. 1997.)

The art of medicine includes malpractice, and Standards of Care are issued as a safeguard against malpractice. Prerequisite medical/legal standards for the proper application of sex-reassignment treatment serve the protection of the consumer as well as the provider.

This statement shows a fundamental ignorance about the Law. The Standards of Care offer no real legal protection against malpractice lawsuits. Even the "informed consent" and "waivers" most surgeons have patients sign prior to surgery hold little legal weight if the surgeon proves to be negligent. To state that the purpose of the HBSOC is to provide legal protection for patients and/or practitioners is dubious at best.

A few remarks concerning Reflections on "Transsexualism and Sex Reassignment" 1969-1999: Presidential Address, August 1999, Richard Green, M.D., J.D.:

It is difficult to identify another psychiatric or medical condition in which the patient makes the diagnosis and prescribes the treatment. . . .The administration overseeing the Gender Identity Clinic at Charing Cross Hospital is besieged by patient complaints. This is mostly because the clinic professionals have not acquiesced quickly enough to the patient’s demands for sex reassignment. The expense of handling these complaints has made the Gender Identity Clinic unpopular with administration and has at times threatened its existence. Unhappily, not only are such patients self-defeating but they make it difficult for the great majority of patients who are in genuine collaboration with professionals.

The situation outlined by this statement appears to be that the complaints could be mitigated entirely by providing sex reassignment surgery when it is requested. This would undoubtedly make Charing Cross Hospital a VERY popular destination for sex reassignment surgery, as well as bringing revenue to the hospital the administration would appreciate. The Gender Identity Clinic would become a valuable ASSET of the hospital, rather than a liability. Also, the statement that "It is difficult to identify another psychiatric or medical condition in which the patient makes the diagnosis and prescribes the treatment" may indicate clinicians aren't truly necessary, especially if the patients will simply keep going to therapists UNTIL they find one that concurs. This only serves to frustrate the patient and act as a roadblock to gaining access to the requested treatments. Perhaps it is difficult to find another such psychiatric condition because it doesn't belong in the DSM-IV catalog of mental illnesses in the first place.

Newer ethical concerns in these 30 years have evolved from whether clinicians should grant a request for sex reassignment, to the question, are clinicians necessary? Should sex change be available on demand? That was hardly the issue in 1969, as the nearly insurmountable hurdle then was professionally endorsed reassignment. If gender patients can procure surgeons who do not require psychiatric or psychological referral, research should address outcome for those who are professionally referred versus the self-referred. Then an ethical issue could be, if success is less (or failure greater) among the self-referred, should otherwise competent adults nevertheless have that autonomy of self-determination?

This passage points out some of the very basic questions about whether or not the HBSOC is necessary or not. Unfortunately the prevalence of the HBSOC itself makes it very difficult for patients to find surgeons who do not require psychiatric or psychological referrals. Supporters of the Harry Benjamin Standards simply DO NOT KNOW if their methodology is the best one, and have created an atmosphere in the medical community that makes it difficult to accurately gauge if it is because there is so little room or willingness to stray radically from the guidelines. This, despite the fact that the HBSOC states:

"Clinical departures from these guidelines may come about because of a patient's unique anatomic, social, or psychological situation, an experienced professional’s evolving method of handling a common situation, or a research protocol. These departures should be recognized as such, explained to the patient, and documented both for legal protection and so that the short and long term results can be retrieved to help the field to evolve."

There ARE ways to "work" the system or do end-runs around it, but always at a greater cost either monetarily or in the quality of care one can receive. A good therapist would be willing to tailor the HBSOC guidelines to the individual patient's situation. There are far too many factors involved in Gender Dysphoria to expect a "one size fits all" therapy to work.

The main thing to keep in mind is what one's relationship will be with the therapist. Unfortunately, though, the structure of the HBSOC forces therapists into the role of "gatekeeper" with the requirements for letters. If a therapist chose not to recommend SRS, they wouldn't be drafting those "letters of recommendation" - which would be a roadblock. Suddenly their "recommendation" becomes "permission." Their "concern" becomes "control." It all depends on an individual's relationship with the therapist - as a "master" or a "mentor," and the patient as a "slave" or a "student?" The key concerning the required therapy is "self discovery." Many transsexuals appear to consider their therapy as "putting in their time" or "going through the motions" and the therapist as an "obstacle" to overcome. They aren't interested in "self-discovery" or exploration of their TRUE selves.

In many ways there are now so many "deviations" from the HBSOC that, in practice, it is much closer to the ICTLEP SOC, and it appears "hard nose" therapists who stick to the Standards like Fundamentalists are becoming rarer. Nevertheless, the HBSOC guidelines and the DSM/ICD criteria and definitions included within them, appear to be full of assumptions, illogical arguments, and contradictions that should be addressed by the medical community, not ignored.

This article is not a "position statement" for this web site, it is provided only for the purposes of illustrating, in detail, the basis for many of the criticisms leveled at the psychological classifications and the Harry Benjamin Standards of Care.