Critical Examination of Selected Issues from the
BENJAMIN INTERNATIONAL GENDER DYSPHORIA ASSOCIATIONS STANDARDS
OF CARE FOR GENDER IDENTITY DISORDERS - SIXTH VERSION (HBSOC-6)
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.
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.
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.
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.
mentioned, the DSM-IV contradicts itself where gender diagnosis is concerned.
In the introduction to the manual it states,
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."
statement is at odds with what it says in the section on Gender Identity
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."
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.
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.
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?")
every adult gender patient requires psychotherapy in order to proceed
with hormone therapy, the real life experience, hormones, or surgery.
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.
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)
for Hormone Therapy for Adults
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.
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.
Criteria. The administration of hormones is not to be lightly
undertaken because of their medical and social risks. Three criteria
1. Age 18
knowledge of what hormones medically can and cannot do and their social
benefits and risks;
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).
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.
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
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
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.
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.
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 patients 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
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."
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.
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.
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."
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.
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:
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.
) 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.
. . . .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.
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?
Be Provided Without Hormones and the Real-life Experience?
surgery is not a right that must be granted upon request.
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.
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.
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.
under which Surgery May Occur.
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.
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."
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!
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" 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?
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
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.
comments on "Sex Reassignment, Harry Benjamin, and some European
Roots" By Friedemann Pfaefflin, M.D.
paper documents the author's Presidential Address at the XV Harry Benjamin
International Gender Dysphoria Symposium, Vancouver, Canada, 7.-18.
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.
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.
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 patients 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
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.
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?
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:
departures from these guidelines may come about because of a patient's
unique anatomic, social, or psychological situation, an experienced
professionals 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."
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.
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.
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,
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.