Another Look at the HBIGDA Standards of Care (1996)

©1996, 2013 by Dallas Denny

Source: Denny, Dallas. (1996, September). Another look at the Benjamin Standards. Renaissance News & Views,10(1), pp. 1,  6. Reprinted in Virginia’s Secrets, September, 1996, pp. 1-2.

Renaissance News & Views Pages (PDF)

Another Look at the Benjamin Standards

By Dallas Denny

The Standards of Care were, literally, just whipped up. Although a considerable number of people were in the committee which developed them, they were, according to sexologist and historian Vern Bullough, almost solely the work of the late psychologist Dr. Paul Walker. They were first written in 1979, based on policies of the newly defunct Gender Identity Clinic at Johns Hopkins University.

The issue under discussion is whether the Harry Benjamin Standards of Care are restrictive. Obviously, something that places formidable obstacles to an individual doing what they want to their own body is an imposition on that individual. So yes, they are restrictive. But are they unnecessarily or arbitrarily so? That is another question.

The Standards of Care are a set of consensual medical standards which, by placing requirements like hormone and surgery letters and a real‑life test on access to medical procedures, make it difficult for most and impossible for some to obtain those medical procedures. They are “minimal” standards; that is, they should supposedly not be bypassed, but can be exceeded. In fact, they have a history of being zealously exceeded (abused is a better word) by mental health professionals. This is because they place the mental health professional (psychiatrist, psychologist, counselor, social worker, family & marital therapist) in the position of okaying/not okaying medical treatment. Surgeons and endocrinologists have surrendered the responsibility of making the decision to those outside the medical community.

This is certainly an unusual move. Other body‑modifying procedures which are, on a purely medical level, as drastic, or more so, than hormonal therapy and SRS, do not require this sort of input from mental health specialists. It seems certain that the Standards were born at least partly out of awe of what the medical procedures could accomplish: “sex change.” They were also born out of a need for medical practitioners to protect themselves from lawsuits.

Certainly, the Standards of Care are less than perfect. They have been described for instance, and with good reason, as sexist and objectifying of female bodies because they classify female breasts as sex organs for purposes of mastectomy/chest reconstruction in female‑to‑males; as being biased against those who cannot afford counseling; and for needlessly linking hormonal therapy and sex reassignment surgery.

There is much reason to ask why access to medical treatment is regulated by the Standards of Care. However, all the Standards of Care do is to regulate hormonal therapy and surgery. All other aspects of sex reassignment are at the discretion of the individual. Surgeons and endocrinologists are sworn to do no harm, and have reasonable concern that allowing ad‑lib access to hormonal therapy and SRS would cause a great deal of human misery. Certainly, the reason they were developed was because such free access in the past had indeed resulted in suicides and wrecked lives. The medical professionals were not trained to do screening for their procedures at the level which was needed; consequently, they passed on the responsibility to mental health professionals. This put mental health professionals in the position of being gatekeepers, with a resulting inevitable deterioration of the therapeutic relationship. The power dynamics inherent in a transexual person seeing a therapist for permission for access to medical procedures makes actual therapy almost impossible, as has been so well‑pointed‑out by Kessler McKenna in their book Gender: An Ethnomethodological Approach, and Anne Bolin in In Search of Eve.

The Standards of Care, which were written in 1979, and have been revised regularly (most recently in 1991; they are currently in revision once again), have served well, but the faults in the infrastructure are showing badly. Most seriously, they couple hormonal therapy and surgery, which means that they apply only to those people who are headed for eventual genital surgery! Incredibly, The Harry Benjamin International Gender Dysphoria Association, the organization which developed the Standards of Care, is currently discussing whether it wants to uncouple these; that’s because about 2/3 of the membership don’t yet realize that there are gay FTMs or MTF lesbians, or that everyone who seeks sex reassignment doesn’t have to be a Barbie or Ken stereotype of a man or woman; and that many who wish to crosslive full time, and so seek hormonal therapy, have no desire for surgery, or for that matter, that some men and women want genital surgery but have no intention of crossliving.

Certainly, in my opinion, the Standards of Care give too much power to the mental health professional and not enough to the individual. Just as certainly, in my opinion, to scrap them in favor of the Emperor’s New Clothes Standards‑‑ excuse me, I.C.T.L.E.P. Health Law Standards, which are in fact no standards at all‑‑ would be a recipe for human misery and would jeopardize the availability of treatment for everyone.

A six‑page set of standards cannot adequately address the diverse needs of the transgender community. We are in need of something much more comprehensive, which allows for consideration of differences in racial, cultural, and religious backgrounds‑‑ and, as has been pointed out by some HBIGDA members‑‑ which is appropriate not just for English speaking countries, but which is truly international.