Do We Need Standards of Care? (1996)

 

When the news of Christine Jorgensen’s medical treatment in Denmark found its way into the popular press in late 1952, both Jorgensen and her endocrinologist, Christian Hamburger found themselves deluged with hundreds of letters from frantic men and women, asking how they could obtain hormones and surgery. Unfortunately, the doctors had no particular intention of doing additional sex reassignments in Denmark, and treatment was available nowhere else.

Many of the letter writers found their way to private practioners for treatment. Dr. Harry Benjamin was the most notable of these. The publication of his book The Transsexual Phenomenon in 1966 introduced the word transsexualism into general use. In the book, Benjamin stressed the importance of counseling and introduced the idea of a real-life-test, in which, as a requirement for sex reassignment surgery, an individual lived 24 hours a day in the new gender role.

In 1967, the U.S.’ first gender clinic opened at Johns Hopkins University. The Hopkins program and the rest of the more than 40 university-affiliated gender programs which developed in the 1960 and 1970s put into place guidelines based on those developed by Dr. Benjamin. Outside the programs, there were no such guidelines. Obtaining surgery in places like Morocco and even from private surgeons in the U.S. required only that one show up with the money, looking sufficiently robust to withstand the anesthetic. Not surprisingly, there were a great many tragedies associated with surgery, as those who had thought they couldn’t live without surgery decided, too late, that they couldn’t live with it.

The guidelines originated by Benjamin and adapted at Johns Hopkins were codified, in 1979, into the Harry Benjamin Standards of Care, a document ostensibly authored by a committee comprised of various medical professionals, but in actuality written almost solely by the late Paul Walker (Ihlenfeld, 1993). They were distributed by the newly formed Harry Benjamin International Gender Dysphoria Association, and appeared in Annals of Plastic Surgery (Walker, et al., 1984) and other journals. They have been widely accepted, and remain the only reasonable treatment guidelines available.

The Harry Benjamin Standards are quite lengthy, but the major way in which they impact transsexual people is by placing a waiting period on access to hormonal and surgical treatment and by requiring a minimum one-year real-life-test before sex reassignment surgery.

In 1992, the International Conference on Transgender Law and Employment Policy published its Health Law Standards, which were in fact a statement of consumer rights. The Health Law Standards would require any physician who performs sex reassignment surgery or prescribes counter-sex hormones to provide them to anyone who requests them, providing only that the individual can give informed consent and has no existing medical condition which would serve as a counterindication.

Unlike the Harry Benjamin Standards, the Health Law Standards have been largely ignored by the medical and psychological communities, and by the majority of trangendered people—and especially, transsexuals. Most people in the transgender community are in favor of some limitations on medical procedures. In a survey conducted in 1993 by AEGIS, 256 of 339 respondents (75.5)% agreed with the Harry Benjamin Standards’ requirement that individuals must be in therapy for a minimum of 90 days before obtaining hormones (Denny & Roberts, 1995). 265 of 339 (78.2%) agreed with the requirement for a one-year real-life test before sex reassignment surgery. And 88% (298 of 339) believed that the Harry Benjamin Standards serve a useful purpose. The sample, which was mailed to readers of the journal Chrysalis and distributed at support groups and gender programs across the U.S. and on the internet, was largely transsexual; more than 77% reported that they had had or planned to have sex reassignment surgery.

While I believe free access to hormonal therapy and surgery is a recipe for human misery, I also recognize that the Standards of Care take control out of the hands of transsexual people and place it squarely in the hands of mental health providers who may or may not have the best interest of their clients at heart. Having such power breeds mistrust and does profound damage to the therapist-client relationship, making the vlaue of therapy questionable (Bolin, 1988).

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 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.

An 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 issue under discussion is whether the Harry Benjamin Standards of Care are restrictive. Obviously, something that places formidable obstacles on 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.

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, HBIGDA, 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 does not have to be Barbie or Ken stereotypes of men and women; 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.

 

References

 

Berger, J.C., et al. (1990). Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Harry Benjamin International Gender Dysphoria Association.

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

Denny, D., & Roberts, J. (1995). Results of a survey of consumer attitues about the HBIGDA Standards of Care. Paper presented at the First International Congress on Gender, Cross Dressing, and Sex Issues, Van Nuys, CA, 23-26 February, 1995.

Hamburger, C. (1953). The desire for change of sex as shown by personal letters from 465 men and women. Acta Endocrinologica, 14, 361-375.

Ihlenfeld, C. (1993). Speech at the 13th International Symposium on Gender Dysphoria, New York City, 21-24 October.

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

Walker, P.A., Berger, J.C., Green, R., Laub, D., Reynolds, C., & Wollman, L. (1984). Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons. Annals of Plastic Surgery, 13(6), 476-481.