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Standards of care for gender identity disorders

In many countries or areas, an individual’s pursuit of sexual reassignment surgery (SRS) is often governed, or at least guided, by documents called standards of care (SOC), or standards of care for gender identity disorders. Various medical and psychiatric fields have developed similar protocols for treatments, covering topics ranging from diabetes patients to sexual abuse survivors.

Prior to the advent of the first SOCs, there was no semblance of a consensus agreement on psychiatric, psychological, medical, and surgical management of gender identity disorders. Before the 1960s, few countries offered safe, legal medical options and many criminalised cross-gender behaviours or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring “lasting personal comfort with the gendered self in order to maximise overall psychological well-being and self-fulfilment.” These standards are still the most well known, however, other sets of SOCs, protocols and guidelines do exist, especially outside the USA.

The HBIGDA Standards of Care for Gender Identity Disorders

These Standards of Care (HBIGDA-SOC) are the most widespread SOC used by professionals working with transgender persons. The HBIGDA-SOC are periodically updated and revised as new scientific information becomes available. The latest revision was released February 20, 2001. This is the sixth version of the HBIGDA-SOC since the original 1979 document was drafted. Previous revisions were released in 1980, 1981, 1990, and 1998. The HBIGDA 18th Biennial Symposium will be held September 10-13, 2003, in Ghent, Belgium, which could mean that yet another revision of the SOC might be available in the near future, considering the rapidly changing field of treatment options as well as patient demands.

Included in the guidelines are sections on epidemiology, mental health professionals, treatment of children, adolescents and adults, hormone replacement therapy, the Real-Life Experience (RLE), which was formerly called the Real-Life Test, and, of course, surgery.

HBIGDA-SOC sections Ten through Twelve (of thirteen) specifically cover the surgical treatment of transsexuals. Section Twelve, titled “Genital Surgery,” deals directly with all concerns about sexual reassignment surgery. It includes six “Eligibility Criteria” and two “Readiness Criteria”, which are intended to be used by professionals for both diagnosis and guidance before providing patients “letters of recommendation.”

The current revision mandates that mental health professionals document a patient’s relevant history in a letter which should be required by medical professionals prior to physical intervention. One letter is required for hormone replacement therapy or either augmentation mammoplasty or mastectomy. Two additional letters are needed for genital surgeries.

The Eligibility Criteria and Readiness Criteria give certain very specific “minimum” requirements as prerequisites to HRT or SRS. For this and many other reasons, the HBIGDA-SOC is a highly controversial and often maligned document among transsexual patients seeking surgery, many of whom claim that their legally protected right to proper medical care and treatment is unjustly and unduly withheld or even denied based on the SOC. This frequent disdain is in spite of and quite possibly the cause of increasingly less stringent professional adherence to the SOC, as well as a general reduction or deletion of some pre-surgical mandates in recent revisions of the HBIGDA-SOC. The majority of qualified surgeons North America and many in Europe adhere almost unswervingly to the HBIGDA-SOC.

Criticism of the HBIGDA-SOC

Numerous criticisms have been made against the HBIGDA-SOC over the course of its history, some of which have been reflected in later versions of the guidelines. Most of these criticisms are related to how stringent the requirements are, noting that the rate of post-surgical regret among transsexuals is generally very low – lower than that of many medically-necessary and many cosmetic procedures that do not have such stringent requirements. Particularly under fire have been the provisions related to the necessity of real-life experience (noting that requiring real-life experience in an incongruous anatomical/social role can be both mentally harmful as well as physically dangerous to the individual) and the SOC’s very strict requirements on the treatment of minors. Under all but the most recent version of the SOC, even hormonal treatment to delay the onset of puberty was forbidden in all cases, leading to often irreversible bodily changes. This has since been changed to allow for hormonal treatment (both hormone blockers and cross-gender hormones) in limited circumstances. The HBIGDA has also removed the set length of time for psychotherapy.

One criticism that has been levied against surgeons who perform SRS, and not the standards themselves, has been the increasingly rare non-SOC practice of requiring patients to have divorced their spouse before performing surgery.

Other SOCs, protocols and guidelines for the treatment of gender identity disorders

In some countries or areas, local standards of care exist, such as in the Netherlands, Germany or Italy. Also, some health care providers have their own set of SOCs which have to followed to have access to health care. The criticism about the HBIGDA-SOCs applies to these as well; some of these SOCs are based on much older versions of the HBIGDA-SOCs, or are entirely independent of them. A more lenient version of the SOC that has been increasing in acceptance is the Health Law Standards Of Care, developed by the Health Law Project (also known as the ICTLEP guidelines), which are based on a harm-reduction model.

Treatment according to such older SOCs is often reserved for transsexuals only, not for other transgender people who for example might not want to undergo the complete set of treatments, or who see themselves outside a binary gender system.

Treatment outside HBIGDA-SOCs

In other regions, most notably Thailand, there are doctors who follow alternative standards and who will actually arrange surgery dates over the Internet and operate on any person who meets financial and other criteria. Some of these surgeons charge as little as one fourth of the fees demanded by the average Western surgeon, and as little as one tenth of the cost of some well-known and highly respected surgeons in the US, while a few more experienced surgeons charge amounts comparable to these fees and are thought by some to often perform superior surgery. A dramatic elevation in surgical and post-surgical risks as well as an increased possibility of post-surgical dissatisfaction is often the exchange for lower costs and fewer pre-surgical requirements such as weight limits. In other regions, notably Latin America, surgeons follow no particular set standards and decide their own criteria for eligibility for surgery.

In Western countries the emphasis is on psychiatry or psychology, typically in Latin America the emphasis is on the ability to “pass” and in Thailand the emphasis is on cross-living experience.

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