Standards of Care: A Critical Review

with Suggested Amendments
(The hormonal and surgical sex re-assignment of gender dysphoric persons)

Dr. Russell W. Reid.

MB, Ch.B, MRC Psych. Consultant Psychiatrist, The London Institute of Human Sexuality. GEMS associate.
Gendys Conference, 1992

INTRODUCTION

In 1979 it was estimated that the number of adult Americans hormonally and surg-ically re-assigned ranged from 3000-6000 persons. Another ten times that number consider them selves valid candidates for sex re-assignment.

The demand for sex re-assignment has increased in recent decades as has the number and variety of psychological hormonal and surgical treatments. Various philosophies of appropriate care have been suggested by various professionals and experts, but the first officially sanctioned statement of the Standards of Care and Principles offered to patients was prepared in 1979 by a committee of the Harry Benjamin International Gender Dysphoria Association.

DEFINITIONS

a. Standards of Care. These are considered to be the minimal rather than the optimum requirments in the treatment of Gender Dysphoric Patients. Some experts of Gender Identity recommend that the time parameters listed below should be doubled or even tripled.

It is recommended that the reasons for any exceptions to these standards in the management of any individual case be very carefully documented. Professional opinions differ regarding the permissibility of, and the circumstances warranting, any such exception.

b. Hormonal Sex Re-assignment refers to the administration of Androgen to genetic females and the administration of estrogens and/or Progesterones to genetic males for the purpose of effecting physical changes in order for the patient to more closely approximate the physical appearance of the other sex.

c. Surgical Sex Re-assignment. Genital surgical sex re-assignment refers to surgery of the genitalia and/or the breasts performed for the purpose of altering the body in order to approximate the appearance of the other sex in persons diagnosed gender dysphoric. These surgical procedures include mastectomy, reduction mammoplasty, augmentation mammoplasty, castration, orchidectomy, penectomy, vaginoplasty, hysterectomy, salpingectomy, vaginectomy, oophorectomy and phalloplasty.

d. Non-genital Sex Re-assignment refers to any and all other surgical procedures of non-genital or non-breast sites, including the nose, throat, chin, cheeks and hips etc, conducted for the purpose of effecting a more masculine appearance in a genetic female or a more feminine appearance in a genetic male.

e. Gender Dysphoria refers to that psycho logical state whereby a person demonstrates dissatisfaction with their sex at birth and sex role as socially defined which applies to that sex, and who requests hormonal and surgical sex re- assignment.

CLINICAL BEHAVIOURAL SCIENTIST/SPECIALIST CLINICIAN.

Persons recommending hormone therapy or sex re-assignment surgery should have documented training and experience in the diagnosis and treatment of:

• A broad range of psychological conditions.
• A broad range of sexual conditions.
• Plus proven competence in general psychotherapy, sex therapy and gender counselling therapy.

The minimal documentable credentials are listed and described in the Standards of Care booklet as they apply to American Practitioners.

31 principles and 16 standards are described and summarised as follows:

Principle 1: Hormonal and surgical sex re-assignment is extensive in its effects, is invasive to the integrity of the human body, has effects and consequences which are not, or not readily reversible, and may be requested by persons experiencing short-term delusions or beliefs which may later be changed and reversed.

Principle 2: Hormonal and surgical sex re-assignment are procedures requiring justification and are not of such minor consequence as to be performed on an elective basis.

Principle 3: Published and unpublished case histories are known in which the decision to undergo hormonal and surgical sex re-assignment was, after the fact, regretted and the final result of such procedures proved to be psychologically debilitating to the patients.

Principle 4: The analysis or evaluation of gender dysphoric patients' reasons, motives, attitudes and purposes requires special skills and training.

Principle 5: Hormonal and/or surgical sex re-assignment is performed for the purpose of improving the quality of life and are best studied and evaluated by Specialist Clinicians.

Principle 6: Hormonal and surgical sex re-assignment are usually offered to persons, in part, because of a psychiatric diagnosis of transexualism as defined in DSM III, or some related diagnosis. Such diagnoses are properly made by Specialist Clinicians.

Principle 7: Specialist Clinicians, in deciding to make the recommendation for hormonal and/or surgical sex re-assignment, share the moral responsibility for that decision with the Physician or Surgeon who accepts that recommendation.

Principle 8: The Specialist Clinician's opinion will be based on their evaluation of how well the patient fits the diagnostic criteria for transexualism (DSM III category 302.5.) as follows:

• a. Sense of discomfort and inappropriateness about one's anatomic sex.
• b. A wish to be rid of one's own genitals and to live as a member of the other sex.
• c. The disturbance has been continuous (not limited to periods of stress) for at least 2 years.
• d. Absence of physical intersex or genetic abnormality.
• e. Not due to another mental disorder, such as schizophrenia.

The diagnosis of Transexualism is operationally defined above and distinguishes Transexualism from Transvestism and effeminate homosexuality.

Principles 9 and 10 refer to intersex and schizophrenic patients.

Principle 11: Hormonal sex re-assignment is therapeutic and diagnostic in that the patient requesting such therapy either reports satisfaction or dissatisfaction regarding the results of such therapy.

Principle 12 refers to certain irreversible effects, particularly the use of Androgens in female to male transexuals.

Principle 13: Hormonal sex re-assignment should precede surgical sex re-assignment since the effects of hormones in terms of patient satisfaction or dissatisfaction may indicate, or contraindicate, later surgical sex re-assignment.

Principals 14 and 15 refer to the possibility that male and female hormones may lead to mild or serious health threatening complications.

Principle 16 requires the Clinician to know independently from the patient that he or she is gender dysphoric and has been for at least 2 years.

Principles 17-20 include reference to peer review or second opinion; the need for caution in relying on patients verbal reports; the fact that many patients may apply extreme social pressure and manipulate the Clinician into doing what the patient wants. The Clinician may not enjoy the security of knowing that decisions concerning gender patients are not necessarily likely to be supported by their peers.

Principle 21 refers to the surgical altering of the genitourinary tract and the need for diagnosis of any associated disorders prior to surgical sex re-assignment.

Principles 22-31 include comments of fees charged for treatment, the fact that hormonal and surgical sex re-assignment is a rehabilitative experience for properly selected adult patients, and such patients must give informed consent for hormonal and surgical sex re-assignment.

Following on from these Principles the following Standards of Care are suggested:

Standard 1.

a. Hormonal and/or sex re-assignment surgery must not be given on demand.

b. Patients must be properly evaluated.

c. An assessment as to the appropriate ness of the patient's reasons for requesting such services, including the beliefs and attitudes upon which such reasons are based.

In other words a proper history must be taken with special reference to gender and sexuality. Patients with mental illness or mental handicap may need to be excluded.

Standard 2.

Hormonal and surgical sex re-assignment must be preceded by a firm written recommendation by a Specialist Clinician able to justify this.

Standard 3.

Refers to intersex patients and schizophrenic patients (the diagnosis of these disorders does not preclude hormonal or surgical sex re-assignment).

Standard 4.

The initiation of hormonal sex re-assignment should be made by a Specialist Clinician.

Standard 5.

The Physician prescribing hormonal medication to a transexual must warn the patient of possible negative complications, and make available to the patient monitoring of relevant blood tests including liver function tests, serum lipids and fasting glucose. (and serum prolactin).

Standard 6.

Specialist Clinicians prescribing hormones shall have known the patient for at least 3 months before recommending hormones.

Standard 7.

A second opinion (peer review) is required for referral for sex re-assignment surgery, but not for hormonal sex re-assignment. One of the two Clinicians must be a Doctor. Non-genital and breast surgery does not require the recommendation of a Clinician.

Standard 8.

The Clinician making the primary recommendation for sex re-assignment surgery shall have known the patient in a psychotherapeutic relationship for at least 6 months.

Standard 9.

Genital sex re-assignment surgery shall be preceded by a period of at least 12 months, during which time the patient lives exclusively in the social role of the genetical other sex.

Standard 10.

Urological examination is necessary prior to sex re-assignment surgery.

Standard 11.

The Surgeon performing sex re-assignment surgery must receive 2 recommendations in favour of such a procedure, one of whom must be a Doctor and one of whom must have known the patient for at least 6 months.

Standard 12.

Charges for patients must be fair and reason able. It is permissible to charge patients in advance for sex re-assignment surgery, and for post-surgical follow-up care of counselling.

It is unethical to charge for services which are for research and those which do not directly benefit the patient.

Standard 13.

Appropriate fees only should be charged.

Standard 14.

Hormonal and surgical sex re-assignment may be provided for persons obtaining their legal majority ie. over 18 years of age.

Standard 15.

Hormonal and surgical sex re-assignment to be provided only after the patient applicant has received full and complete explanations, preferably in writing, and understandable, of all the risks inherent in the requested procedures.

Standard 16.

The privacy of the medical record of the patient shall be safeguarded as with any other patient.

HIDDEN AGENDA OF STANDARDS OF CARE

• To protect doctors and surgeons from litigious patients. This applies particularly in the USA.
• To produce a uniformity and conformity in the medical/surgical treatment of gender disordered patients (and prevent maverick surgeons from operating on demand by anyone and allcomers).
• To set up a pretty stiff obstacle course to deter all but the most determined transexuals.

NON-HIDDEN AGENDA TO MAINTAIN PROPER TREATMENT STANDARDS AND PREVENT UNSUITABLE PATIENTS FROM BEING RE-ASSIGNED.

To weed out potentially unsuitable patients one needs to check the outcome studies; (see ref: Clinical Management of Gender Identity Disorders in Children and Adults, Chapter 9, Gender Reorientation and Psychosocial Adjustment.)

SPECIAL UNITED KINGDOM CONSIDERATIONS

A necessary principle must be to include links with patient's General Practitioner in order for the GP to prescribe hormones, do regular physical health checks including blood pressure and weight, to do blood tests and, lately, for GP's to be able to initiate ECR's for NHS sex reassignment surgery.

PERSONAL SUGGESTIONS FOR AMENDMENTS TO STANDARDS OF CARE

• For persons clearly diagnosed as Male to Female Transexual, a trial of feminising hormones may be prescribed earlier in the assessment period than the three months suggested by the Harry Benjamin Guidelines. A detailed explanation of the limitations of hormones effects, their risks, benefits and side effects must be given to patients before prescribing them. Their effects are reversible for up to a year and produce pleasing physical and psychological changes in genuinely transexual patients. Feminising hormones function as a diagnostic test to confirm genuinely transexual patients, and, because of their anti-libidinal effects, effectively weed out and deter non-genuine transexuals including fetishistic transvestites and homosexual drag queens.
• For female to male transexuals a delay of from 3-6 months seems reasonable before prescribing masculinising hormones, in view of their irreversible effects including hirsutism and deepening of the voice.
• Change of gender role should not be a prerequisite for the prescribing of hormones, or even the continued prescribing of hormones after one or two years, although this of course is not particularly desirable.
• After a detailed evaluation with the conclusion that the patient is gender dysphoric, and most likely transexual, hormones may be recommended and prescribed regardless of the person's intention or not to change gender roles. It should NOT be the doctor's job to tell patients how to behave or how to live their lives or in which gender role they should live. This decision is up to the patient to do, or not, in his or her own good time, and in their own way. In this way the patient, and not the doctor, takes responsibility for the outcome, the credit for success and the blame for failure. Obviously discussion of a timetable and options for progressing towards cross-gender living, cautiously or rapidly, do need to be discussed and the implications thought through very carefully.
• Divorce need not be a prerequisite for surgical referral. The following disclaimer is acceptable:
  "I, . . . . . . . . hereby acknowledge that my partner/husband intends to undergo gender re-assignment surgery. I acknowledge that this is an irreversible operation involving the removal of penis and testicles for the condition of male to female transexualism. I also acknowledge and understand that after the operation marital/sexual relationships will not be possible and I accept this situation."
• The psychiatrist/clinician's role is to facilitate the process by enlightening their patients about the pro's and con's of hormones as well as the reasons for the requirement of a period of exclusive cross gender living prior to a surgical referral.
• The psychiatrist should be perceived as an ally rather than an obstacle maker and gatekeeper for hormones and surgery.
• There should be greater flexibility for early referral in certain cases, such as older patients approaching 65, when a delay in surgery may increase the risks involved, or when a patient threatens self-mutilation, or has already been driven to self-mutilate (attempt auto-castration), as well the option, when appropriate for patients to be recommended orchidectomy early on, as an alternative to the use of anti-androgen, Androcur.
• There should be a study of, and register of, persons who's gender dysphoria is "phasic" and who change their minds either in the pre- or post-op phase of their disorder. Are such patients different from the others who don't change their minds? Is the condition of phasic gender dysphoria diagnosable and predictable by any means early on in order to prevent these disasters, or is the whole process of changing gender roles and having hormonal and surgical sex re-assignment necessary in order to exorcise the demon of their gender dysphoria?

REFERENCES.

1. Standards of Care, Harry Benjamin International Gender Dysphoria Association, available in this country from The Beaumont Trust.
2. Clinical Management of Gender Identity Disorders in Children and Adults, Blanchard and Steiner, American Psychiatric Press Inc.
3. Transvestites and Transexuals - Towards a theory of cross-gender behaviour, Dr. Richard F. Docter, Plenum Press (USA)