My Invited Comments on Proposed Revision of HBIGDA Standards of Care (1997)

Denny, Dallas. (1996, December). Vision 2001: A Gender Odyssey. Part IV: Local organizations, publications, “those darn professionals.” AEGIS News, 1(9), pp. 1-6 (see pp.5-6 for my comments on the in-process revision of the HBIGDA Standards of Care).

Brown, George. R. (1997, May). Letter to the editor. AEGIS News, 1(10), pp. 2-3.

Denny, Dallas. (1997, May). Response to George R. Brown. AEGIS News, 1(10), p. 5.

Denny, Dallas. (1997, May). Comments on proposed SOC revision. AEGIS News, 1(10), pp. 3-6.

Some months ago, Alice Webb, HBIGDA’s Executive Director, was ambushed by the HBIGDA Board and forced to resign. HBIGDA has claimed that she resigned of her own volition, but statements by Ms. Webb and several HBIGDA board members clearly show that the resignation was forced. There is concern in the transgender community that the old school researchers and clinicians have taken over the organization. This is not a farfetched theory. Stephen Levine, who is certainly of the “old school, “is head of the revision committee for the Standards of Care. Last year, the HBIGDA newsletter noted that Levine, in his suggestions for revision of the Standards, believes that post-op transsexuals have no need for therapy “Asks what is the value of Principle 23, which states that some persons\ are in need of post [surgery] therapy. He feels that it indicates the pre-surgery therapy was inadequate” (Highlights of the Harry Benjamin International Gender Association Meeting, Kloster Irsee, Germany, September 7-10, 1995, p. 5.) Some of Levine’s other suggestions seem homophobic, value-laden, and overly controlling (see the box on this page). I personally am very uncomfortable that someone who believes that surgery is a magical cure for everything that ails transsexuals has been made chair of the committee which will revise the Standards of Care.

Fortunately, HBJGDA members will have an opportunity to review and comment upon the proposed revisions before they become final. However, considering the unsubtle sacking of Alice Webb, I suspect the Committee’s recommendations will carry. I predict trouble if the revised Standards of Care give more control of transgender and transsexual lives to professionals.

Certainly, AEGIS will not support more stringent Standards unless there is factual and unequivocal documentation that they are needed— and imagine, will other transgender organizations or the majority of the newer generation of community-trained caregivers accept more stringent standards. HBIGDA will certainly be singing its swan song if the new Standards are what I fear they will be.

 

Stephen B. Levine’s More Objectionable Suggestions

For Revisions of Standards of Care

 

Would like Standards of Care to make cosmetic surgeries such as breast augmentation, cricoid cartilage shaving, vocal cord lengthening, etc. processes that need permission from the treating professional.

Association should take a stand on whether SRS should be done on HIV+ patients. He believes it is unfair to the surgeons to allow this, but would be willing to modify his view when an effective treatment for AIDS is a reality.

Asks what is value of Principle 23, which states that some persons are in need of post-surgery therapy. He feels that it indicates that pre-surgery therapy was inadequate.

He feels the Standards of Care do not adequately reflect difficulties of treating GID patients as regards many phone calls, 50% drop-out rate before first appointment, high loss to follow-up after evaluation, frequent mind-changing and major characterological difficulties.

—From the HBIGDA publication Highlights of the Harry Benjamin International Gender Association Meeting, Kloster Irsee, Germany, September 7-10, 1995, p. 5.

I am very much concerned about your premature attacks, in the last issue of AEGIS News (#9, 12/96—Ed.), on the [forthcoming revision of the ] Standards of Care. You may wish to publish some or all of this e-mail as a “letter to the editor,” as others could benefit from what will be only the first part of a lengthy dialogue over the next year. Given that you have not read any of the five drafts that we have worked very hard on over the last eight months, such attacks are unwarranted and inaccurate. Dr. Levine is not writing the revision, but is coordinating the very difficult process of gaining consensus from an international committee from many fields. I am the adult psychiatrist on the committee, and I can assure you this process has been inclusive and intense. Prior to your attack on the SOC revision I had already put your name in as one of two recommendations I made for outside review comments to incorporate into the sixth draft. I made this recommendation based on your work, your dedication to the transgender community, and your perspective as a trained mental health care professional who has been a consumer of care for transgendered persons.

Before condemning the chair (Dr. Levine), the volunteer committee member, or our evolving work, please take the time to review its current incarnation. There are many changes. We must not be naive, however, in expecting a final draft that is either without controversy or devoid of critics with diverse agendas.

I look forward to your comments on the latest draft.

Sincerely,

George R. Brown, M.D.

Chief of Psychiatry

Mountain Home VAMC

Board of Directors, HBIGDA

Committee Member, SOC Revisions

The reason I brought this up in AEGIS News rather than waiting was because I was alarmed by a presentation about the proposed revisions given at a gender community event by one of the committee members, and by Dr. Levine’s incredible (I thought) statements in an issue of the HBIGDA newsletter that post-operative transsexuals  who need therapy were poor candidates for surgery. I considered that the longer I waited before bringing up my concerns, the closer the new SOC would be to being set in stone. I agree, though, that I should not have made the matter personal by singling out Dr. Levine.

I thank you for submitting my name as a reviewer of the proposed SOC revision. Dr. Levine sent me the draft, and I was able to give committee members my feedback (reproduced in this issue). And I do appreciate the committee’s hard work.

I remain concerned that the draft I read considers increasing rather than decreasing psychiatric gatekeeping. In fact, last night I dreamed I was at the forthcoming HBIGDA conference in Vancouver, wearing a t-shirt that read “Vote no on the proposed SOC revisions.” I hope the final draft will allay my concerns, making such a t-shirt unnecessary.

19 March, 1997

Stephen B. Levine, M.D.

Chairperson, SOC Committee

Dear Dr. Levine:

Thank you for giving me the opportunity to look over the proposed revision for the Harry Benjamin Standards of Care. I have enclosed my comments on the document.

I regret not meeting your 1 March deadline, but the several weeks I was given for review were not sufficient to digest and comment upon the substantive changes in this revision of the Standards of Care.

I have enclosed my comments, and have taken the liberty of sending them to the other members of the committee.

Sincerely,

Dallas Denny, M.A.

Licensed Psychological Examiner

The driving force behind the Standards of Care was the late Paul Walker. When they first appeared in 1979, they brought order in a time of chaos. Consider: the infamous 1979 Meyer & Reter study had just been published, gender programs were closing their doors all over North America, Janice Raymond’s The Transsexual Empire had just been published, and the federal government, at Ms. Raymond’s urging, was studying sex reassignment (Raymond, 1980). Transsexuals were turning to professionals who had little or no previous experience with sex reassignment, and who had little idea about what was or was not considered ethical (Ogas, 1994).

The Standards of Care provided clear consensual minimal guidelines for the provision of medical procedures to modify the bodies of transsexuals. The fact that the Standards have survived for nearly 20 years with only minor revision is a testament to the wisdom and foresight of Dr. Walker.

Now it is the nineties. Things have changed dramatically, especially in the last five years. Whereas in 1979, people seriously seeking access to hormones and genital surgery were called transsexuals and desired to assimilate into society as members of the “other” gender, transgendered people today are much more diverse (Denny, 1997a). Some wish to cross-live without genital surgery; some wish to achieve an androgynous or “in-between” state, and some want traditional sex reassignment, with genital surgery. Those wishing access to medical technology may or may not identify as transsexual. Also, we now have a more well-developed literature– one in which the psychoanalytic interpretations of transsexualism which once prevailed have been discredited, and which suggests that transsexuals as a class are not particular impaired in any area other than the desire to change their sex– and that impairment, when it does occur, may be due much more to discrimination against transsexuals by others than to any inherent pathology in the transsexuals (Cole, et al., 1997).

While the ongoing major revolution in ways of thinking about gender and sex reassignment certainly poses challenges to the current Standards of Care, I think great care should be taken in revision—especially since the previous balance of power has, in the opinion of some—myself included—given too much power to clinicians at the expense of robbing transsexuals of their autonomy. Certainly, there is compelling evidence that the power games which arise because of the gatekeeping required by the Standards is detrimental to the therapeutic relationship (Bolin, 1988, 1994, 1997). Also, the very real question “Why do transsexuals require special permissions not required of other groups of people” has never been adequately answered (Health Law Standards of Care, 1993).

I believe firmly that unrestricted access to hormones and surgery would be disastrous. However, I am well aware that empirical evidence is lacking that adherence to the Standards of Care improves outcome. This is very unfortunate, for it ensures that revisions of the Standards will be based on the clinical experience and insights of those who make those revisions– and it has been well-documented that the impressions of transsexualism and transsexuals gained from the 50 minute therapy hour are quite different from those gained from studying transsexuals in real-life settings (cf Bolin, 1988). With no offense meant to clinicians, I think it is time that the Standards of Care address the realities of transsexual lives and not just what the therapist seems when an often-desperate transsexual comes to him or her for help.

Rather than engage in criticism of the minutiae of the proposed revisions, I would like to address my concerns in a more molar fashion. Hence;

A Positive Comment

I am most impressed with the committee’s clear understanding that access to medical treatment is sought by all sorts of individuals and that there are a variety of ways of dealing with transgender feelings, ranging from periodic crossdressing to traditional sex reassignment. This is quite a breakthrough, and the committee deserves to be commended for it. Many other aspects of the document are commendable as well– for instance, the move away from the term “Clinical Behavioral Scientist” (which, I understand, was confusing to those on continents other than North America). I really like the clear use of language throughout the document.

The proposed Standards are based upon the view (but one of many) that the desire to have access to body-changing medical technologies is inherently a sign of disorder.

In my judgement, this is not true. While I will not dispute the fact that some people who wish to access this technology may have something called gender identity disorder, others may not. The change of the title from Standards of care: The hormonal and surgical sex reassignment of gender dysphoric persons to Standards of Care for Gender Identity Disorders is unfortunate. Are the Standards meant to apply only to those with “gender identity disorder?” If so, then what about those who are not diagnosable and wish to access the technology? Are they left out in the cold? Or are they eligible for access to the technology without adhering to the Standards?

I believe the bottom line here should be not whether one has a “disorder,” but what one must do in order to access body-changing technologies. The Standards should divorce themselves from diagnostic criteria and clinical judgments and make access contingent upon clear behavioral criteria (such as the real-life test). Thus, not only “transsexuals,” but transgenderists, androgynes, drag queens and kings, and Elvis impersonators like Elvis Herselvis will all be eligible if they meet the required criteria (see Bockting, 1997). In fact, I believe that if transsexuals must meet SOC requirements in order to access these technologies, nontranssexuals should also; therefore, any woman wishing breast augmentation or reduction or any man desiring surgery for gynecomastia should be subject to the same sort of safeguards as transsexuals.

Speaking as a veteran of a gender program (Vanderbilt University) at which I was denied access to hormones and surgery technologies because I was not sufficiently dysfunctional (Denny, 1997b), I cannot emphasize enough how important I think it is to divorce access criteria from psychopathology. In fact, there is no need whatsoever for the term “disorder” to be in the Standards of Care document, and I would like to see it removed entirely. The idea that transsexualism is a disorder is but one of many ways of looking at transgender phenomena (Denny, 1997). I know that there has been an effort to make the Standards less North-American centric and truly international; if they are to be international standards for access, and not a crutch to prop up the medical colonization of transgendered and transsexual persons, then they must be divorced from the idea of disorder, because many societies (for instance, Polynesian cultures) do not consider transgender behavior to be pathological. In other words, there is no inherent need to medicalize transsexuals by declaring them disordered simply because they desire access to medical technology.

The proposed Standards do not adequately address the issues of female-to-male persons

Feminist scholars (cf Bolin, 1992) have rightly pointed out that female bodies are much more likely to be commodified than those of males. This was certainly true in the original Standards of Care, which defined the breasts as “genitals.” I am unaware of any other context in which breasts are considered to be genitals. Certainly, augmentation or reduction of breasts is not regulated except in transsexuals. Any woman (or man) who wants breast augmentation or reduction can simply go to a plastic surgeon and get it. Why should transsexuals be any different? The only logical reason is because the original Standards, and the current proposed Standards, consider transsexuals to be disordered for wanting the same thing as many nontranssexual men and women.

Breasts are not genitals.

In a survey I conducted several years ago, only 30% of 339 respondents indicated that they believed that the breasts of female-to-male transsexuals should be considered genitals. Consider this in contrast to the findings that 75% thought a period of evaluation before hormonal therapy a good idea, and 78% agreed with the idea of a mandatory one-year real-life test before SRS. (Denny & Roberts, 1997).

I asked James Green, a female-to-male transsexual and the Director of FTM International about this issue, and he wrote, via e-mail:

The various FTM surgeries must be recognized as separate medical and social issues. An FTM may require a hysterectomy or a breast reduction for reasons other than ‘GID’ and yet because of the ‘GID’ may want these procedures to be done differently than they would be done for a non-transsexual woman. Also, if a non-transsexual woman desires breast augmentation or reduction surgery, she is not required to be diagnosed with a mental disorder; neither is a male with gynecomastia.

James also made the valid point that the statement, on p. 13, that hormones “… do not significantly alter physical appearance within a short period of time” is not true of many FTMs. Changes in FTMs can be very dramatic; within a matter of 2 to 4 months an individual once identifiable as female can appear as a bearded, low-voiced, balding, hirsute man.

James indicated that physical changes in FTMs can include: skin coarsening, changes in body odor, body hair growth, male pattern baldness, weight gain, increased muscle mass, increased appetite, and blood sugar/glucose metabolism changes.

Proposals to Increase Requirements for Access to Treatment

I find it incredible that there is even a consideration of requiring a period of full-time crossliving before initiation of hormonal therapy. The American Educational Gender Information Service has taken a strong position against such periods of mandatory RLT before hormones (see enclosed), and is in the process of querying its advisory board about issuing an opinion that such a requirement is not only inadvisable but constitutes professional malpractice except in the occasional case in which the individual has serious medical conditions which increase the risk of hormonal therapy. It is AEGIS’ opinion that the social disruption caused by undertaking the RLT far outweighs the medical risks of hormones. In fact, undertaking RLT before the individual is physically prepared is a prescription for failure, as it increases risk of discrimination, ridicule, and hostility from others.

It seems that throughout the document, the responsibility for trauma resulting from mistreatment of transsexuals by society is laid on transsexuals, further pathologizing them, rather than on a corrupt society in need of reform. I think the Standards of Care need to clearly state that mistreatment of an individual because of his or her nonconforming gender appearance and/or behavior is a sign of pathology in the mistreating party rather than the transsexual. James thinks– and I concur– that the Standards need to include a statement that the practitioner who subscribes to them has a duty to work to end societal discrimination against transsexuals.

I find the proposal for required psychotherapy equally unwarranted. There is no real evidence that transsexuals need such treatment, and I consider it would be unethical to require it. It’s one thing to make sure an individual knows what he or she is getting into (which is in my opinion what is actually happening in the therapeutic process in the majority of cases these days), and quite another to force him or her into ongoing treatment that may or may not be needed or wanted.

Surgical treatments other than SRS (breast augmentation and reduction), rhinoplasty, tracheal shave) should not require letters of authorization from therapists.

Gender Programs

The document states that treatment in interdisciplinary settings is preferable to treatment in other settings. I do not think that there is evidence to support this; there are in fact, many outcome studies from gender programs, but there is nothing to compare them to. I have been following members of a support group in the Southeastern United States for some six years now; these persons usually make their own decisions about what treatments to have and when they will get them, and most choose to have only the minimum amount of therapy needed to require various authorization letters. I will be presenting some of my rather surprising findings at the HBIGDA conference in September. Among other things I have found that of more than 70 post-process transsexuals, not a single one has been lost to follow-up (which suggests that the oft-lamented “lost to follow-up” problem is due not to the unreliability and uncooperativeness of transsexuals, as has been suggested in the literature, but to negative feelings interdisciplinary treatment settings engender in transsexuals). I have also found the number of positive outcomes in the support group to be equivalent to those reported by the most positive studies reported by gender programs (see attached abstract).

Last Words

In the current Standards of Care, we have a document which, if not perfect, is working quite well. Furthermore, as shown by the Denny & Roberts (1977) study, they have the overwhelming support of the transgender community.

In the past, I have called for dialogue between the professional and transgender communities before the existing Standards of Care are altered. Although the work of the SOC revision committee has been laudable, the proposed changes do not reflect the necessary input from transsexuals and other transgendered persons; my input at this late date, and the presence of one transsexual on the committee simply do not suffice. I think the committee must ask itself the hard question: would it impose such restrictive standards on women as a class, or on Blacks, or on homosexuals, without adequate representation on the committee from members of those communities? I think not, and I think that for this reason the committee must stop and ask itself why things have happened to this point the way that they have. I think that soul-searching will show that things are seriously amiss, and that much work needs to be done, at theoretical and empirical and grassroots level, before the existing Standards of Care are changed in any appreciable way, whether to make access to medical technologies easier, or to make them more difficult.

Thank you.

cc SOC Revision Committee members

References

 

Bockting, W.O. (1997). Transgender coming out: Implications for the clinical management of gender dysphoria. In B. Bullough, V. Bullough, & J. Elias (Eds.), Gender blending, pp. 48-52. Amherst, NY: Prometheus Press.

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

 Bolin, A.E. (1992b). Gender subjectivism in the construction of transsexualism. Chrysalis Quarterly, 1(3), 22-26, 39.

Bolin, A.E. (1994). Transcending and transgendering: Male-to-female transsexuals, dichotomy, and diversity. In G. Herdt (Ed.), Third sex, third gender: Essays from anthropology and social history, pp. 447-485. New York: Zone Publishing.

Bolin, A. (1997). Transforming transvestism and transsexualism: Polarity, politics, and gender. In B. Bullough, V. Bullough, & J. Elias (Eds.), Gender blending, pp. 25-32. Amherst, NY: Prometheus Press.

 

 Cole, C., O’Boyle, M., Meyer, W.J., III, & Emory, L.E. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26(1), 13-26.

Denny, D. (1997a). Transgender: Some historical, cross-cultural, and modern-day models and methods of coping & treatment. In B. Bullough, V. Bullough, & J. Elias (Eds.). Gender blending, pp. 33-47. Amherst, NY: Prometheus Books,=,

Denny, D. (1997b). Coming of age in the land of two genders. In B. Bullough, V. Bullough, M.A. Fithian, W.E. Hartman, & R.S. Klein (Eds.), Personal stories of “How I got into sex”: Leading researchers, sex therapists, educators, prostitutes, sex toy designers, sex surrogates, transsexuals, crimologists, clergy, and more…, pp. 75-86. Amherst, NY: Prometheus Press.

Denny, D., & Roberts, J. (1997). Results of a survey of consumer attitudes about the HBIGDA Standards of Care. In B. Bullough V. Bullough, & J. Elias (Eds.). Gender blending, 320-336. Amherst, NY: Prometheus Books.

 Health Law Standards of Care. (1993). Houston, TX: International Conference on Transgender Law and Employment Policy, Inc.

 Meyer, J.K., & Reter, D. (1979). Sex reassignment: Follow-up. Archives of General Psychiatry, 36(9), 1010-1015.

Ogas, O. (1994, 9 March). Spare parts: New information reignites a controversy surrounding the Hopkins gender identity clinic. City Paper (Baltimore), 18(10), cover, 10-15.

Raymond, J. (1979). The transsexual empire: The making of the she-male. Boston: Beacon Press. Reissued in 1994 with a new introduction by Teacher’s College Press, New York.

Raymond, J.G. (1980). Paper prepared for the National Center for Health Care Technology on the social and ethical aspects of transsexual surgery. Rockville, MD: National Center for Health Care Technology.