AEGIS Medical Advisory: Blanket Criterion for RLT Before Hormones is Unethical (1992)

17 February, 1998 (Original release date 12/3/92)

Medical Advisory Bulletin

Blanket Criterion for Real-Life Test Before Hormones is Unethical

The Problem

A number of gender clinics, including the Clarke Institute of Psychiatry in Toronto, have a blanket cri­terion for the initiation of hormonal therapy: the individual must make the necessary arrangements to change gender roles and cross-live on a full-time basis for an extended period of time before hormonal ther­apy is initiated. The reasons for this requirement have been given as clinical judgement, a need for the indi­vidual to experience the new gender role before mak­ing irreversible hormonal changes, and concern about some of the effects of hormones and the medical risks involved in their administration. Usually, this criteri­on seems to have been set up as a roadblock, with the idea that those who want sex reassignment badly enough will persevere, no matter what the obstacle.

Advisory

It is our position that the psychological and social effects which occur as a result of preparing for and beginning a period of full-time cross-living are in most cases potentially far more disruptive than the lingering effects or physical dangers of a short period on hormones. We believe that requiring a mandatory period of real-life experience before initiation of hor­monal therapy can be and often is harmful, and is in fact unethical behavior. While we agree that the indi­vidual should have experience in the new gender role, we urge practitioners and clinics who adhere to this unethical practice to change it. [1, 21

Discussion

Hormones are not without danger, and some of their effects, like breast development in the genetic male and hirsutism and voice-deepening in the genet­ic female, are indeed permanent. Hormones should be administered only with care and in accordance with the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc.; that is, the individual should have been in therapy for at least 90 days and should have been given a diag­nosis of gender identity disorder by an experienced clinician. Before hormonal therapy is initiated, care should be taken to rule out other conditions which can masquerade as transsexualism. However, clients should not be manipulated by the therapist or required to “prove” their diagnosis.

Real-life experience does not occur in a vacuum. Friends and family must be informed, marriages must be dissolved, and accommodations must be made at work—if the individual is fortunate enough to keep his or her position. Not only the primary client, but others are affected: parents, children, husbands and wives, neighbors, employers, co-workers.

The result of failed hormonal therapy is at worst some physical characteristics which run counter to type and which may be difficult for the individual to explain. The result of a failed real-life experience is a life in shambles. Family, friends, and employers can­not be un-told about transsexualism, marriages and family life are unlikely to be resumed, and lost employment is unlikely to be regained. A non-pass­able appearance, which is likely if the individual has not been on hormones for a significant period, can be highly stigmatizing, and can place the individual in physical danger in this era of hate crimes. Furthermore, a failed real-life experience can result in a high potential for self-destructive behavior, includ­ing suicide.

A stigmatizing appearance is not necessarily a contraindication for sex reassignment, but it is cer­tainly a disadvantage, and one which can be lessened by the provision of hormonal therapy prior to actual changing gender role. The individual who has had such treatment is more likely to be viable— and therefore successful—when the role of choice is assumed.

Globally denying needed medical treatment, including hormonal therapy, in persons diagnosed as transsexual, or making it contingent on the individ­ual structuring his or her lifestyle according to the demands of the caregiver or clinic is in our opinion needlessly obstructionistic, a holdover from the days of less sophisticated treatment.

We believe that although conservativism is usual­ly given as a reason for requiring cross-living before initiation of hormonal therapy, it is not in reality a conservative approach, except from the purely med­ical standpoint of the effect hormones have on the body—a narrow viewpoint, in light of the profound and largely irreversible social changes the real-life experience requires.

[1]     Administration of small doses of estrogens has proved to be a useful tool in differential diagnosis. Male transvestic fetishists on a regimen of estrogens are likely to show reduced desire for sex reassignment.

[2]     Procedures such as orchidectomy, hysterectomy, or sex reassignment surgery should not be performed before the individual is living successfully in the gen­der of choice. This is in accordance with the HBIG­DA Standards of Care. We support the Standards of Care.

This advisory was prepared after consultation with the AEGIS Interdisciplinary Advisory Board