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Another Look at the HBIGDA Standards of Care (1996)

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


I would like to preface the following by stating that I have been a licensed mental psychological examiner since 1979, and have been actively working in the mental health field since 1971, and with transsexual people since 1988. I am also transsexual, post-op five years. I have been and remain an advocate of common sense in the provision of medical treatment to transgendered and transsexual persons, and that means that I believe that access to such treatment should be limited to those who are thinking clearly about all of the ramifications of that treatment– which means that those in a frenzy to get hormones or surgery should calm down and work through their issues and learn all they can about how such treatment will effect their bodies and their lives. To some extent that means walking the walk and talking the talk; that is, engaging in a real-life test, in which one cross-lives full-time, 24 hours a day. Transsexual people do not automatically understand how their lives will be after surgery, or how hormones will effect their sex drive, or how they will be perceived by others in public during and after hormonal therapy or after surgery. Also, many transsexual people have frantic bursts of activity following years of self-denial, which are followed by more years of self-denial. Ground gained during the relatively brief active periods is regretted during the denial phase; certainly this includes extensive body modifications.

With this said, I must also say that I have seen nothing and have read nothing in the literature which suggests that as a class transsexual people are any more or less capable of making decisions than are other categories of persons. There must be clear and demonstrable reasons for limiting access to medical treatment, and the present treatment structure, which is based upon a document known as the Harry Benjamin Standards of Care, must be looked at rationally, and not as permanently etched stone tablets sent directly from God, or from Dr. Benjamin. It is especially important to look at the ways in which the Standards of Care have negatively impacted the therapeutic relationship by giving unprecedented power to mental health professionals to grant or withhold permission for medical treatment to transsexual and transgendered persons.

And so I offer the following, which I wrote on-line on the internet newsgroup alt.transgendered one night as part of a thread about the Standards of Care. I wrote it in about 30 minutes and sent it immediately, without even proofreading it. Typographic errors have been corrected, and I have clarified a few points, but otherwise, these are my original words, and I stand by them.


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.


Berger, J.C., et al. (1990). Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Available from The World Professional Association for Transgender Health.

Bolin, A. (1988). In search of Eve: Transsexual rites of passage. South Hadley,MA: Bergin & Garvey Publishers, Inc.

Kessler, S.J., & McKenna, W. (1978). Gender: An ethnomethodological approach. New York: John Wiley & Sons. Reprinted in 1985 by The University of Chicago Press.

Vern Bullough. (ca 1993) Personal communication at Fantasia Fair, Provincetown, MA.