No Regets: The Standards of Care (1991)

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No Regrets
The Standards of Care
By Dallas Denny

The Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA), is an organization with a membership which is comprised of psychologists, psychiatrists, surgeons, and others who provide professional services to transsexual persons.  Headquartered in Palo Alto, California, HBIGDA publishes Standards of Care which are regularly revised.  The Standards of Care are minimal guidelines for the treatment of persons with transsexualism. They were last revised in 1990.

Until the late 1970s, there were no clear guidelines for the surgical and hormonal treatment of transsexual people. Service providers had no one to look to for suggestions for treatment of their transsexual clients. Consequently, quality of care and requirements for sex reassignment varied widely, ranging from virtual surgery on demand to needlessly restrictive and in some cases nearly impossible criteria. In the absence of guidelines, many service providers, fearing litigation, refused to treat people with transsexualism. HBIGDA set out to bring order out of this chaos. The Standards of Care, which were first published in 1979, were the result.

The Standards safeguard service providers (psychologists, psychiatrists, endocrinologists, and others), as well as transsexual men and women. They lay down a clearly defined series of progressive steps, which begin with diagnosis and cumulate in sex reassignment surgery (SRS). They also define the ethics of treatment of transsexual persons, mandating, for instance, that privacy be safeguarded and that unreasonable fees not be levied.

The Standards allow transsexual men and women to see clearly where they are and what they must do to get where they want to be. They are a series of discrete steps which are easy to understand. They allow the individual with transsexualism to plan and to set goals, and to make contracts and agreements with service providers—to make a master plan for transition.

Most importantly, the Standards of Care set a behavioral criterion for SRS: real-life test. Successful negotiation of real-life test (living and working for a minimal time in the gender of choice) is grounds for referral for surgery.

The Standards are a road map for service providers, telling them what they must do, at minimum, to provide competent care to transsexual people. To the majority of service providers, who are ignorant about transsexualism, the Standards can serve as a cookbook, giving them the necessary confidence to treat men and women they might not otherwise agree to serve.

The Standards are not unreasonable, requiring only 1) diagnosis, before beginning hormonal therapy, by a clinical behavioral scientist (i.e., a licensed or certified psychologist, counselor, social worker, or psychiatrist with special training in human sexuality); and 2) proof of success in real-life test, as documented by two clinical behavioral scientists (one at the doctoral level) before sex reassignment surgery.

Unfortunately, some transsexual men and women look upon the requirements of the Standards as hurdles, resenting them, and coming to view with disfavor psychologists and physicians, and even other transsexual people, who abide by them. For example, in 1990, an entire issue of the magazine Gender Expressions was a radical reaction to the Standards of Care, calling for surgery on demand and deeming those who believed in the Standards “SOC-ups.” Unfortunately, while attacking the Standards of Care, the authors offered nothing to replace them.

While the majority of people with transsexualism are reasonably well-adjusted, there are a few with extreme psychopathology. Additionally, there are any number of men and women who are not transsexual, but who demand sex reassignment. Surgeons and those who prescribe counter-sex hormones have a responsibility to society and to the individual. They must be certain that the individual will not later regret having had invasive hormonal and surgical treatment.

The Standards are more carefully put-together than you might realize. They allow bail-out at any point. Until the day of SRS, it is possible at any point to abandon plans for sex reassignment and successfully return to one’s original gender, with a minimum of disruption. Of course, the further down the road of sex reassignment one walks, the more compromised one will be, but then, the further down the road one walks, the lower the probability that the course will be reversed. By placing it at journey’s end, the Standards ensure that few people will regret the dramatic and irreversible process of sex reassignment surgery.

Some Suggestions for HBIGDA

It is perhaps unfortunate that the Standards are minimal rather than optimal. Some gender clinics and individual service providers have unfortunately been overzealous in their treatment of transsexual persons. This can be very damaging. For instance, the gender program at the University of Minnesota reportedly requires success in real-life test before the initiation of counter-sex hormones. This unfortunately does not take into account the extreme physical difficulty many individuals have before their habitus is changed by hormones. A “man-in-a-dress” appearance causes negative societal reactions; this can lead to psychological trauma, and in addition can be physically dangerous in an era when gay-bashing is all too common. And all the while the cellular clock is ticking, making the probability of successfully passing in the future more and more unlikely.

Similarly, some service providers require unrealistic periods of real-life test—more than five years, in some instances— requiring the individual to live with what has become a physical deformity and a barrier to normal sexual relations long after he or she has been successfully integrated in society. As there are no guarantees that SRS will ever be approved (or even that the service provider ever had any intention of approving SRS, and has not just been stalling), one’s life can be bled away.

Consequently, my first suggestion to HBIGDA is this: Formulate optimal Standards of Care. These need not replace the current minimal standards. They would instead serve as a supplement, to let service providers and transsexual people know what is reasonable and appropriate, or at least what is the norm. It would be simple to gather data about current treatment—HBIGDA need only write those who currently treat transsexual people and ask them for their requirements.

My second suggestion is to make the current Standards more behavioral in nature. While the real-life test requirement does just that, and while the criteria for transsexualism in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM III-R) are entirely behavioral in nature (and endorsed by HBIGDA), the definition of success in the real-life test is not operationalized—that is, defined in behavioral terms.

Can success be defined as merely wearing a dress for one year? Of course not. The individual must be fully functional, and that means living and working in the gender of choice. HBIGDA realizes this, and so speaks of “successfully” living in the gender of choice. Currently, however, the definition of “success” is left to the service provider, who may have unrealistic and stereotyped notions of masculine and feminine functioning to which the transsexual person may choose not to subscribe.

Adding measurable criteria for “success” in real-life test could only improve the Standards of Care.

The Standards of Care are available for $4.00 pls $3.00 P&H from The American Educational Gender Information Service (AEGIS), P.O. Box 33724, Decatur, GA 30033