(The following document is provided as
a reference guide for all those who wish to undergo treatment for
GID/transgender issues (transition). These are the standards by which most
doctors in the U.S., Canada, and several other countries use to determine
eligibility for hormones and/or surgery. It may seem like just another set
of "hoops" for you to jump through in your transition, but the guidelines in
this document are used by health professionals as a means to better your
transition, form a course of treatment, and above all, to communicate with
each other to avoid misdiagnosis, and health/mental health complications.
These are, however, only guidelines and are not "set in stone". Your "team"
of health professionals will determine whether or not you can skip a step or
two, based upon your health, mental state, and life experience.
Even if your therapist, and/or your hormone
prescribing physician, do not follow these standards.....MOST SURGEONS
FOLLOW THEM TO THE LETTER, so don't be surprised if you have to get
multiple letters from mental health providers other than your regular
therapist to get surgery. If you live in
Canada, the national healthcare system requires all health professionals to
follow these guidelines to the letter, as well as guidelines provided by a
committee of physicians and mental health providers.)
HARRY BENJAMIN INTERNATIONAL GENDER
DYSPHORIA ASSOCIATION'S
THE STANDARDS OF CARE FOR GENDER IDENTITY DISORDERS: Fifth Edition
Committee Members:
Stephen B. Levine MD (Chairperson), George Brown MD, Eli Coleman PhD., Peggy
Cohen-Kettenis PhD, J. Joris Hage MD, Judy Van Maasdam MA, Maxine Petersen
MA,
Friedemann Pfafflin, MD, Leah C. Schaefer EdD.
------------------------------------------------------------------------------------------------------------------------------
Consultants: Dallas Denny MA, Domineco DiCeglie MD, Wolf
Eicher MD, Jamison Green, Richard Green MD,
Louis Gooren MD, Donald Laub MD, Anne Lawrence MD, Walter Meyer III MD, C.
Christine Wheeler PhD
------------------------------------------------------------------------------------------------------------------------------
TABLE OF CONTENTS
PART ONE–Introductory
Concepts
PART TWO–Brief
Reference Guide to the Standards of Care
PART THREE--The Full
Text of the Standards of Care
-Epidemiological
Considerations
-Diagnostic Nomenclatures
-The Mental Health Professional
-The Treatment of Children
-The Treatment of Adolescents
-Psychotherapy with Adults
-The Real Life Experience
-Requirements for Hormone Therapy
for Adults
-Hormone Therapy for Adults
-Requirements for Genital Reconstructive and Breast Surgery
-Surgery
1This is the fifth version of the Standards of Care
since the original 1979 document.
Previous revisions were accepted in 1980, 1981, and 1990.
PART ONE--INTRODUCTORY
CONCEPTS
The Purpose of the Standards of Care. The major purpose of the
Standards of Care (SOC) is
to articulate this international organization's professional consensus about
the psychiatric,
psychological, medical, and surgical management of gender identity
disorders. Professionals may
use this document to understand the parameters within which they may offer
assistance to those
with these problems. Persons with gender identity disorders, their families,
and social
institutions may use the SOC as a means to understand the current thinking
of professionals. All
readers should be aware of the limitations of knowledge in this area and of
the hope that some of
the clinical uncertainties will be resolved in the future through scientific
investigation.
The Overarching Treatment Goal.
The general goal of the specific psychotherapeutic, endocrine, or surgical
therapies for people with gender identity disorders is lasting personal
comfort with the gendered self in order to maximize overall psychological
well-being and self fulfillment. The Standards of Care Are Clinical
Guidelines. The SOC are intended to provide flexible directions for the
treatment of gender identity disorders. When eligibility requirements are
stated they are meant to be minimum requirements. Individual professionals
and organized programs may raise them. Clinical departures from these
guidelines may come about because of a patient's unique anatomic, social, or
psychological situation, an experienced professional's evolving method of
handling a common situation, or a research protocol. These departures should
be recognized as such, explained to the patient, documented both for legal
protection and so that the short and long term results can be retrieved to
help the field to evolve.
The Clinical Threshold. A
clinical threshold is passed when concerns, uncertainties, and questions
about gender identity persist in development, become so intense as to seem
to be the most important aspect of a person's life, or prevent the
establishment of a relatively un-conflicted gender identity. The person's
struggles are then variously informally referred to as a gender identity
problem, gender dysphoria, a gender problem, a gender concern, gender
distress, or transsexualism. Such struggles are known to be manifested from
the preschool years to old age and have many alternate forms. These forms
come about by various degrees of personal dissatisfaction with sexual
anatomy, gender demarcating body characteristics, gender roles, gender
identity, and perceptions of others. When dissatisfied individuals meet
specified criteria in one of two official nomenclatures--the International
Classification of Diseases-10 (ICD-10) or the Diagnostic and Statistical
Manual of Mental Disorders--Fourth Edition (DSM-IV)--they are formally
designated as suffering from a gender identity disorder (GID). Some persons
with GID exceed another threshold--they persistently possess a wish for
surgical transformation of their bodies.
Two Primary Populations with GID
Exist--Biological Males and Biological Females. The sex of a patient always
is a significant factor in the management of GID. Clinicians need to
separately consider the biological, social, psychological, and economic
dilemmas of each sex. For example, when first requesting professional
assistance, the typical biological female seems to be further along in
consolidating a male gender identity than does the typical biological male
in his quest for a comfortable female gender identity. This often enables
the sequences of therapy to proceed more rapidly for male-identified
persons. All patients, however, must follow the SOC.
[Back to Top]
PART TWO A BRIEF REFERENCE GUIDE TO THE STANDARDS OF CARE
CAVEAT–It is recommended that no one use this guide without consulting the
full text of
the SOC (Part Three) which provides an explication of these concepts.
I. Professional involvement with patients
with gender identity disorders involves any of the
following:
A. Diagnostic assessment
B. Psychotherapy
C. Real life experience
D. Hormonal therapy
E. Surgical therapy.
II. The Roles of the Mental Health
Professional with the Gender Patient. Mental health professionals (MHP) who
work with individuals with gender identity disorders may be regularly called
upon to carry out many of these responsibilities:
A. To accurately diagnose the
individual's gender disorder according to either the DSM-IV or ICD-10
nomenclature
B. To accurately diagnose any co-morbid psychiatric conditions and see to
their appropriate treatment
C. To counsel the individual about the range of treatment options and
their implications
D. To engage in psychotherapy
E. To ascertain eligibility and readiness for hormone and surgical therapy
F. To make formal recommendations to medical and surgical colleagues
G. To document their patient's relevant history in a letter of
recommendation
H. To be a colleague on a team of professionals with interest in the
gender identity disorders
I. To educate family members, employers, and institutions about gender
identity disorders
J. To be available for follow-up of previously seen gender patients.
III. The Training of Mental Health
Professionals
A. The Adult-Specialist
1. basic clinical competence in
diagnosis and treatment of mental or emotional disorders
2. the basic clinical training may occur within any formally
credentialing discipline--for example, psychology, psychiatry, social
work, counseling, or nursing.
3. recommended minimal credentials for special competence with the
gender identity disorders:
a. master's degree or its equivalent
in a clinical behavioral science field granted by an institution
accredited by a recognized national
or regional accrediting board.
b. specialized training and competence in the assessment of the
DSMIV/ICD-10 Sexual Disorders (not simply gender identity disorders)
c. documented supervised training and competence in psychotherapy.
d. continuing education in the treatment of gender identity disorders.
B. The Child-Specialist
1. training in childhood and
adolescent developmental psychopathology.
2. competence in diagnosing and treating the ordinary problems of
children and adolescents.
IV. The Differences between Eligibility
and Readiness Criteria for Hormones or Surgery.
A. Eligibility--the specified criteria
that must be documented before moving to a next step in a triadic
therapeutic sequence (real life experience, hormones, and surgery)
B. Readiness--the specified criteria that rest upon the clinician's
judgment prior to taking the next step in a triadic therapeutic sequence
V. The Mental Health Professional's
Documentation Letters for Hormones or Surgery Should Succinctly Specify:
A. The patient's general identifying
characteristics
B. The initial and evolving gender, sexual, and other psychiatric
diagnoses
C. The duration of their professional relationship including the type of
psychotherapy or evaluation that the patient underwent
D. The eligibility criteria that have been met and the MHP's rationale for
hormones or surgery
E. The patient's ability to follow the Standards of Care to date and the
likelihood of future compliance
F. Whether the author of the report is part of a gender team or is working
without benefit of an organized team approach
G. The offer of receiving a phone call to verify that the documentation
letter is authentic.
VI. One-Letter is Required for Instituting
Hormone Treatment;Two-Letters are Required for Surgery
A. Two separate letters of
recommendation from mental health professionals who work alone without
colleagues experienced with gender identity disorders are required for
surgery and
1. If the first letter is from a
person with a master's degree, the second letter should be from a
psychiatrist or a clinical psychologist--those who can be expected to
adequately evaluate co-morbid psychiatric conditions.
2. If the first letter is from the patient's psychotherapist, the second
letter should be from a person who has only played an evaluative role
for the patient. Each letter writer, however, is expected to cover the
same seven elements
B. One letter with two signatures is
acceptable if the mental health professionals conduct their tasks and
periodically report on these processes to a team of other mental health
professionals and non-psychiatric physicians.
VII. Children with Gender Identity
Disorders
A. The initial task of the
child-specialist mental health professional is to provide careful
diagnostic assessments of gender-disturbed children.
1. the child's gender identity and
gender role behaviors, family dynamics, past traumatic experiences, and
general psychological health are separately assessed. Gender-disturbed
children differ significantly along these parameters.
2. hormonal and surgical therapies should never be undertaken with this
age group.
3. treatment over time may involve family therapy, marital therapy,
parent guidance, individual therapy of the child, or various
combinations.
4. treatment should be extended to all forms of psychopathology, not
simply the gender disturbance.
VIII. Treatment of Adolescents
A. In typical cases the treatment is
conservative because gender identity development
can rapidly and unexpectedly evolve. Teenagers should be followed,
provided
psychotherapeutic support, educated about gender options, and encouraged
to pay
attention to other aspects of their social, intellectual, vocational, and
interpersonal
development.
B. They may be eligible for beginning triadic therapy as early as age 18,
preferably with parental consent.
1. Parental consent presumes a good
working relationship between the mental health professional and the
parents, so that they, too, fully understand the nature of the GID.
2. In many European countries sixteen to eighteen-year-olds are legal
adults for medical decision making, and do not require parental consent.
In the United States, age 18 is legal adulthood.
C. Hormonal Therapy for Adolescents.
Hormonal treatment should be conducted in two phases only after puberty is
well established.
1. in the initial phase biological
males should be administered an antiandrogen (which neutralize
testosterone effects only) or an LHRH agonist (which stops the
production of testosterone only)
2. biological females should be administered sufficient androgens,
progestins, or LHRH agonists (which stops the production of estradiol,
estrogen, and progesterone) to stop menstruation.
3. second phase treatments--after these changes have occurred and the
adolescent's mental health remains stable
a. biologic males may be given
estrogenic agents
b. biologic females may be given higher masculinizing doses of
androgens
c. second phase medications produce irreversible changes
D. Prior to Age 18. In selected cases,
the real life experience can begin at age 16, with or without first
phase hormones. The administration of hormones to adolescents younger
than age 18 should rarely be done.
1. first phase therapies to delay
the somatic changes of puberty are best carried out in specialized
treatment centers under supervision of, or in consultation with, an
endocrinologist, and preferably, a pediatric endocrinologist, who is
part of an interdisciplinary team.
2. two goals justify this intervention
a. to gain time to further explore
the gender and other developmental issues in psychotherapy
b. to make passing easier if the adolescent continues to pursue
gender change.
3. in order to provide puberty
delaying hormones to a person less than age 18, the following criteria
must be met
a. throughout childhood they have
demonstrated an intense pattern of
cross-gender identity and aversion to expected gender role behaviors
b. gender discomfort has significantly increased with the onset of
puberty
c. social, intellectual, psychological, and interpersonal
development are limited as a consequence of their GID
d. serious psychopathology, except as a consequence of the GID, is
absent
e. the family consents and participates in the triadic therapy
E. Prior to Age 16. Second phase
hormones, those which induce opposite sex characteristics should not be
given prior to age 16 years.
F. Mental Health Professional Involvement is an Eligibility Requirement
for Triadic Therapy During Adolescence.
1. To be eligible for the
implementation of the real life experience or hormone therapy, the
mental health professional should be involved with the patient and
family for a minimum of six months.
2. To be eligible for the recommendation of genital reconstructive
surgery or mastectomy, the mental health professional should be
integrally involved with the adolescent and the family for at least
eighteen months.
3. School-aged adolescents with gender identity disorders often are so
uncomfortable due to negative peer interactions and a felt incapacity
to participate in the roles of their biologic sex that they refuse to
attend school.
a. Mental health professionals
should be prepared to work collaboratively with school personnel to
find ways to continue the educational and social development of
their patients.
IX. Psychotherapy with Adults
A. Many adults with gender identity
disorder find comfortable, effective ways of identifying themselves
without the triadic treatment sequence, with or without psychotherapy
B. Psychotherapy is not an absolute requirement for triadic therapy.
1. Individual programs vary to the
extent that they perceive the need for psychotherapy.
2. When the mental health professional's initial assessment leads to a
recommendation for psychotherapy, the clinician should specify the goals
of treatment, estimate its frequency and duration.
3. The SOC committee is wary of insistence on some minimum number of
psychotherapy sessions prior to the real life experience, hormones, or
surgery but expects individual programs to set these
4. If psychotherapy is not done by members of a gender team, the
psychotherapist should be informed that a letter describing the
patient's therapy may be requested so the patient can move on to the
next phase of rehabilitation.
C. Psychotherapy often provides
education about a range of options not previously seriously considered by
the patient. Its goals are:
1. to be realistic about work and
relationships
2. to define and alleviate the patient's conflicts that may have
undermined a stable lifestyle and to attempt to create a long term
stable life style
3. to find a comfortable way to live within a gender role and body
D. Even when the initial goals are
attained, mental health professionals should discuss the likelihood that
no educational, psychotherapeutic, medical, or surgical therapy can
permanently eradicate all psychological vestiges of the person's original
sex assignment
X. The Real-Life Experience
A. Since changing one's gender role has
immediate profound personal and social consequences, the decision to do so
should be preceded by an awareness of what these familial, vocational,
interpersonal, educational, economic, and legal consequences are likely to
be.
B. When clinicians assess the quality of a person's real-life experience
in the new gender role, the following abilities are reviewed
1. to maintain full or part-time
employment
2. to function as a student
3. to function in community-based volunteer activity
4. to undertake some combination of items 1-3
5. to acquire a new (legal) first or last name
6. to provide documentation that persons other than the therapist know
that the patient functions in the new gender role.
XI. Eligibility and Readiness Criteria for
Hormone Therapy for Adults
A. Three eligibility criteria exist.
1. age 18 years
2. demonstrable knowledge of what hormones medically can and cannot do
and their social benefits and risks
3. Either a documented real life experience should be undertaken for at
least three months prior to the administration of hormones, Or
4. a period of psychotherapy of a duration specified by the mental
health professional after the initial evaluation (usually a minimum of
three months) should be undertaken
5. under no circumstances should an person be provided hormones who has
neither fulfilled criteria #3 or #4.
B. Three readiness criteria exist:
1. the patient has had further
consolidation of gender identity during the reallife
experience or psychotherapy
2. the patient has made some progress in mastering other identified
problems
leading to improving or continuing stable mental health
3. hormones are likely to be taken in a responsible manner
C. Hormones can be given for those who
do not initially want surgery or a real life experience. They must be
appropriately diagnosed, however, and meet the criteria stated above for
hormone administration.
XII. Requirements for Genital
Reconstructive and Breast Surgery
A. Six eligibility criteria for various
surgeries exist and equally apply to biological males and biological
females
1. legal age of majority in the
patient's nation
2. 12 months of continuous hormonal therapy for those without a medical
contraindication
3. 12 months of successful continuous full time real-life experience.
Periods of returning to the original gender may indicate ambivalence
about proceeding and should not be used to fulfill this criterion
4. while psychotherapy is not an absolute requirement for surgery for
adults, regular sessions may be required by the mental health
professional throughout the real life experience at a minimum frequency
determined by the mental health professional.
5. knowledge of the cost, required lengths of hospitalizations, likely
complications, and post surgical rehabilitation requirements of various
surgical approaches.
6. awareness of different competent surgeons
B. Two readiness criteria exist
1. demonstrable progress in
consolidating the new gender identity
2. demonstrable progress in dealing with work, family, and interpersonal
issues resulting in a significantly better or at least a stable state of
mental health.
XIII. Surgery
A. Genital, Breast, and Other Surgery
for the Male to Female Patient
1. Surgical procedures may include
orchiectomy, penectomy, vaginoplasty, augmentation mammaplasty, and
vocal cord surgery.
2. Vaginoplasty requires both skilled surgery and postoperative
treatment. Three techniques are: penile skin inversion, pedicled
rectosigmoid transplant, or free skin graft to line the neovagina
3. Augmentation mammaplasty may be performed prior to vaginoplasty if
the
physician prescribing hormones and the surgeon have documented that
breast enlargement after undergoing hormonal treatment for two years is
not sufficient for comfort in the social gender role. Other surgeries
that may be performed to assist feminization include: reduction thyroid
chondroplasty, liposuction of the waist, rhinoplasty, facial bone
reduction, face-lift, and blephoroplasty.
B. Genital and Breast Surgery for the
Female to Male Patient.
1. Surgical procedures may include
mastectomy, hysterectomy, salpingo-oophorectomy, vaginectomy,
metoidioplasty, scrotoplasty, urethroplasty, and phalloplasty.
2. Current operative techniques for phalloplasty are varied. The choice
of techniques may be restricted by anatomical or surgical
considerations. If the objectives of phalloplasty are a neophallus of
good appearance, standing micturition, and/or coital ability, the
patient should be clearly informed that there are both several separate
stages of surgery and frequent technical difficulties which require
additional operations.
3. Reduction mammaplasty may be necessary as an early procedure for some
large breasted individuals to make the real life experience feasible.
4. Liposuction may be necessary for final body contouring
C. Post Surgical Follow-up by
Professionals.
1. Long term postoperative follow-up
is one of the factors associated with a good psychosocial outcome.
2. Follow-up is essential to the patient's subsequent anatomic and
medical health and to the surgeon's knowledge about the benefits and
limitations of surgery
a. Postoperative patients may
incorrectly exclude themselves from follow-up with the physician
prescribing hormones as well as their surgeon and mental health
professional.
b. These clinicians are best able to prevent, diagnose and treat
possible long-term medical conditions that are unique to the
hormonally and surgically treated.
c. Surgeons who are operating on patients who are coming from long
distances should include personal follow-up in their care plan.
d. Continuing long-term follow-up has to be affordable and available
in the patient's geographic region.
e. Postoperative patients also have general health concerns and
should undergo regular medical screening according to recommended
guidelines
3. The need for follow-up extends
beyond the endocrinologist and surgeon, however, to the mental health
professional, who having spent a longer period of time with the patient
than any other professional, is in an excellent position to assist in
any post-operative adjustment difficulties.
[Back to Top]
PART THREE THE FULL TEXT OF THE STANDARDS OF CARE
Introduction. This section
provides an in depth understanding of the Standards of Care. It supplies
comprehensive information about the matters either not contained in The
Brief Reference Guide or listed there only in an abbreviated fashion. This
explication of the SOC is intended for all readers--professionals, patients,
family members, and institutional personnel who have to make decisions about
those with gender identity disorders.
I.
EPIDEMIOLOGICAL CONSIDERATIONS
Prevalence. When the gender identity disorders first came to
professional attention, clinical perspectives were largely focused on how to
identify candidates for sex reassignment surgery. As the field matured,
professionals recognized that some persons with bona fide gender identity
disorders neither desired nor were candidates for sex reassignment surgery.
The earliest estimates of prevalence for adults were stated as 1 in 37,000
males and 1 in 107,000 females. The most recent information of the
transsexual end of the gender identity disorder spectrum from Holland is 1
in 11,900 males and 1 in 30,400 females. Four observations, not yet firmly
supported by systematic study, increase the likelihood of a higher
prevalence: 1) unrecognized gender problems are occasionally diagnosed when
patients are seen with anxiety, depression, conduct disorder, substance
abuse, dissociative identity disorders, borderline personality disorder,
other sexual disorders and intersexed conditions; 2) some nonpatient male
transvestites, female impersonators, and male and female homosexuals may
have a form of gender identity disorder; 3) the intensity of some persons'
gender identity disorders fluctuates below and above a clinical threshold;
4) gender variant behavior among female-bodied individuals tends to
relatively invisible to the culture, particularly to mental health
professionals and scientists.
Natural History of Gender Identity
Disorders. In the past, so much attention had been paid to the
therapeutic sequence of cross-gender living, administration of cross-sex
hormones, and genital (and other) surgeries that some made the erroneous
assumption that a diagnosis of GID inevitably should lead to this sequence.
A diagnosis of GID actually only creates a serious consideration of an array
of complex options, only one of which is medical support for this triadic
therapeutic sequence. Ideally, prospective data about the natural history of
gender identity struggles would inform all treatment decisions. These are
lacking except for the demonstration that most boys with gender identity
disorder outgrow their wish to become a girl without therapy. Five less
firmly scientifically established factors prevent clinicians from
prescribing the triadic
therapeutic sequence based on diagnosis alone: 1) some carefully diagnosed
persons spontaneously change their aspirations; 2) others make more
comfortable accommodations to their gender identities without medical
interventions; 3) others give up their wish to follow the triadic sequence
during psychotherapy; 4) some gender identity clinics have an unexplained
high drop out rate; and 5) the percentage of persons who are not benefited
from the triadic sequence varies significantly from study to study.
Cultural Differences in Gender
Identity Disorders Throughout the World. Even if epidemiologic
studies established that a similar base rate of gender identity disorders
existed all over the world, it is likely that cultural differences from one
country to another would alter the behavioral expressions of the disorder.
Moreover, access to treatment, cost of treatment, the therapies offered and
the social attitudes towards the afflicted and the professionals who deliver
care differ broadly from place to place. While in most countries, crossing
gender boundaries more reliably generates moral outrage rather than
compassion, there are striking examples in certain cultures how the
cross-gendered behaviors of spiritual leaders are not stigmatized.
[Back to Top]
II.
DIAGNOSTIC NOMENCLATURES
The Five Elements of Clinical Work.
Professional involvement with patients with gender identity disorders
involves any of the following: diagnostic assessment, psychotherapy, real
life experience, hormonal therapy, and surgical therapy. This section
provides a background on the first stage--diagnostic assessment.
The Development of a Nomenclature. The term 'transsexual'
emerged into professional and public usage in the 1950s as a means of
designating a person who aspired to or actually lived in the anatomically
contrary gender role, whether or not hormones had been administered or
surgery had been performed. During the 1960s and 1970s, clinicians used the
term “true transsexual.” The true transsexual was thought to be a person
with a characteristic path of atypical gender identity development that
predicted an improved life from a treatment sequence that culminated in
genital surgery. They were thought to have: 1) cross-gender identifications
that were consistently expressed behaviorally in childhood, adolescence, and
adulthood; 2) minimal or no sexual arousal to cross-dressing; and no
heterosexual interest (relative to their anatomic sex). True transsexuals
could be of either sex. “True transsexual” males were distinguished from
males who arrived at the desire to change their gender via a reasonably
masculine behavioral developmental pathway. Belief in the true transsexual
concept for males dissipated when it was realized that: 1) such patients
were rarely encountered; 2) those who requested genital reconstructive
surgery more commonly had adolescent histories of fetishistic cross-dressing
or autogynephilic fantasies without cross-dressing; 3) some of the original
true transsexuals had falsified their histories to make their stories match
the earliest theories about the disorder. The concept of “true transsexual”
females never created diagnostic uncertainties, largely because patient
histories were relatively consistent and gender variant behaviors, such as,
female crossdressing, remained unseen by clinicians. The term ‘gender
dysphoria syndrome’ was then adopted to designate the presence of a gender
problem in either sex until psychiatry developed an official nomenclature.
The diagnosis of Transsexualism was
introduced in the DSM-III in 1980 for gender dysphoric individuals who
demonstrated at least two years of continuous interest in removing their
sexual anatomy and transforming their bodies and social roles. Others with
gender dysphoria could be either diagnosed as Gender Identity Disorder of
Adolescence or Adulthood Nontranssexual Type or Gender Identity Disorder Not
Otherwise Specified (GIDNOS). These diagnostic terms were ignored by the
media who used the term transsexual for any person who wanted to change or
had changed sex.
THE DSM-IV. In 1994, the
DSM-IV committee replaced the diagnosis of Transsexualism with Gender
Identity Disorder. Depending on their age, those with a strong and
persistent crossgender identification and a persistent discomfort with his
or her sex or a sense of inappropriateness in the gender role of that sex
were to be diagnosed as Gender Identity Disorder of Childhood (302.6),
Adolescence, or Adulthood (302.85). For persons who did not meet the
criteria, Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6)
was to be used. This category included a variety of individuals--those who
desire only castration or penectomy without a concomitant desire to develop
breasts; those with a congenital intersex condition; those with transient
stress-related cross-dressing; those with considerable ambivalence about
giving up their gender roles. Patients with GID and GIDNOS were to be
subclassified according to the sex of attraction: attracted to males;
attracted to females; attracted to both; attracted to neither. This
sub-classification on the basis of orientation was intended to assist in
determining over time whether individuals of one orientation or another
fared better in particular approaches; it was not intended to guide
treatment decisions.
Between the publication of DSM-III and
DSM-IV, the term "transgendered" began to be used in various ways. Some
employ it to refer to those with unusual gender identities in a value free
manner–that is, without a connotation of psychopathology. Some professionals
informally use the term to refer to any person with any type of gender
problem. Transgendered is not a diagnosis, but professionals find it easier
to informally use than GIDNOS, which is ICD-10. The ICD-10 now provides five
diagnoses for the gender identity disorders (F64):
Transsexualism (F64.0) has three
criteria:
1. The desire to live and be accepted
as a member of the opposite sex, usually accompanied by the wish to make
his or her body as congruent as possible with the preferred sex through
surgery and hormone treatment
2. The transsexual identity has been present persistently for at least
two years
3. The disorder is not a symptom of another mental disorder or a
chromosomal abnormality
Dual-role Transvestism (F64.1) has
three criteria:
1. The individual wears clothes of the
opposite sex in order to experience temporary membership in the opposite
sex
2. There is no sexual motivation for the cross-dressing
3. The individual has no desire for a permanent change to the opposite
sex
Gender Identity Disorder of
Childhood (64.2) has separate criteria for girls and for boys.
For girls:
1. The individual shows persistent and
intense distress about being a girl, and has a stated desire to be a boy
(not merely a desire for any perceived cultural advantages to being a
boy) or insists that she is a boy.
2. Either of the following must be present:
a. persistent marked aversion to
normative feminine clothing and insistence on wearing stereotypical
masculine clothing
b. persistent repudiation of female anatomical structures, as
evidenced by at least one of the following:
1. an assertion that she has, or
will grow, a penis
2. rejection of urination in a sitting position
3. assertion that she does not want to grow breasts or menstruate
3. The girl has not yet reached puberty
4. The disorder must have been present for at least 6 months
For boys:
1.The individual shows persistent and
intense distress about being a boy, and has a desire to be a girl, or,
more rarely, insists that he is a girl
2. Either of the following must be present:
a. preoccupation with stereotypic
female activities, as shown by a preference for either cross-dressing
or simulating female attire, or by an intense desire to participate in
the games and pastimes of girls and rejection of stereotypical male
toys, games, and activities
b. persistent repudiation of male anatomical structures, as evidenced
by at least one of the following repeated assertions:
1. that he will grow up to become
a woman (not merely in the role)
2. that his penis or testes are disgusting or will disappear
3. that it would be better not to have a penis or testes
3. The boy has not yet reached puberty
4. The disorder must have been present for at least 6 months
Other Gender Identity Disorders
(F64.8) has no specific criteria
Gender Identity Disorder,
Unspecified has no specific criteria.
Either of the previous two diagnoses could
be used for those with an intersexed condition. The purpose of the DSM-IV
and ICD-10 is to organize and guide treatment and research. These
nomenclatures were created at different times and driven by different
professional groups through a consensus process. There is an expectation
that the differences between the systems will be eliminated by the year
2000. At this point, the specific diagnoses are based to a larger extent on
clinical reasoning than on scientific investigation. It has not been
sufficiently studied, for instance, whether sexual attraction patterns
predict whether or not a patient will be a mentally healthier person in five
years with or without the triadic sequence. The Gender Identity Disorders
are Mental Disorders. To qualify as a mental disorder, any behavioral
pattern must result in a significant adaptive disadvantage to the person and
cause personal mental suffering. The DSM-IV and ICD-10 have defined hundreds
of mental illnesses which vary in onset, duration, pathogenesis, functional
disability, and treatability. The designation of Gender Identity Disorders
as mental disorders is not a license for stigmatization or for the
deprivation of gender patients' civil rights. The use of a formal diagnosis
is an important step in offering relief, providing health insurance
coverage, and generating research to provide
more effective future treatments.
[Back to Top]
III. THE MENTAL HEALTH PROFESSIONAL
The Ten Tasks of the Mental Health Professional. Mental health professionals
(MHP) who
work with individuals with gender identity disorders may be regularly called
upon to carry out
many of these responsibilities:
1. to accurately diagnose the individual's gender disorder;
2. to accurately diagnose any co-morbid psychiatric conditions and see to
their appropriate
treatment;
3. to counsel the individual about the range of treatment options and their
implications;
4. to engage in psychotherapy
5. to ascertain eligibility and readiness for hormone and surgical therapy;
6. to make formal recommendations to medical and surgical colleagues;
7. to document their patient's relevant history in a letter of
recommendation;
8. to be a colleague on a team of professionals with interest in the gender
identity disorders;
9. to educate family members, employers, and institutions about gender
identity disorders;
10. to be available for follow-up of previously seen gender patients.
The Training of Mental Health Professionals.
The Adult-Specialist. The education of the mental health professional who
specializes
in adult gender identity disorders rests upon basic general clinical
competence in diagnosis and
treatment of mental or emotional disorders. The basic clinical training may
occur within any
formally credentialing discipline--for example, psychology, psychiatry,
social work, counseling,
or nursing. The following are the recommended minimal credentials for
special competence with
the gender identity disorders:
1. A master's degree or its equivalent in a clinical behavioral science
field. This or a more
advanced degree should be granted by an institution accredited by a
recognized national or
regional accrediting board. The mental health professional should have
written credentials
from a proper training facility and a licensing board.
2. Specialized training and competence in the assessment of the
DSM-IV/ICD-10 Sexual
Disorders (not simply gender identity disorders).
3. Documented supervised training and competence in psychotherapy.
4. Continuing education in the treatment of gender identity disorders which
may include
attendance at professional meetings, workshops, or seminars or participating
in research
related to gender identity issues.
The Child-Specialist. The professional who evaluates and offers therapy for
a child or
early adolescent with GID should have been trained in childhood and
adolescent developmental
psychopathology. The professional should be competent in diagnosing and
treating the ordinary
problems of children and adolescents.
The Differences between Eligibility and Readiness. The SOC provides
eligibility
requirements for hormones and surgery. Without first meeting eligibility
requirements, the
patient and the therapist should not request hormones or surgery. An example
of an eligibility
requirement is: a person must live full time in the preferred gender for
twelve months prior to
genital reconstructive surgery. To meet this criterion, the professional
needs to document that the
real life experience has occurred for this duration. Meeting readiness
criteria--further
consolidation of the evolving gender identity or improving mental health in
the new or confirmed
gender role--is more complicated because it rests upon the clinician's
judgment. The clinician
might think that the person is not yet ready because his behavior frequently
contradicts his stated
needs and goals.
The Mental Health Professional's Relationship to the Endocrinologist and
Surgeon. Mental
health professionals who recommend hormonal and surgical therapy share the
legal and ethical
responsibility for that decision with the physician who undertakes the
treatment. Hormonal
treatment can often alleviate anxiety and depression in people without the
use of additional
psychotropic medications. Some individuals, however, need psychotropic
medication prior to, or
concurrent with, taking hormones or having surgery. The mental health
professional is expected
to make these decisions and see to it that the appropriate psychotropic
medications are offered to
the patient. The presence of psychiatric co-morbidities does not necessarily
preclude hormonal
or surgical treatment, but some diagnoses pose difficult treatment dilemmas
and may delay or
preclude the use of either treatment.
The Mental Health Professional's Documentation Letters for Hormones or
Surgery Should
Succinctly Specify:
1. The patient's general identifying characteristics
2. The initial and evolving gender, sexual, and other psychiatric diagnoses
3. The duration of their professional relationship including the type of
psychotherapy or
evaluation that the patient underwent
4. The eligibility criteria that have been met and the MHP’s rationale for
hormones or
surgery
5. The patient's ability to follow the Standards of Care to date and the
likelihood of future
compliance
6. Whether the author of the report is part of a gender team or is working
without benefit of
an organized team approach
7. That the sender welcomes a phone call to verify the fact that the mental
health
professional actually wrote the letter as described in this document.
The organization and completeness of these letters provide the
hormone-prescribing physician
and the surgeon an important degree of assurance that mental health
professional is
knowledgeable about gender issues and is competent in conducting the roles
of the mental health
professional.
One Letter is Required for Instituting Hormone Therapy. One letter from a
mental health
professional, including the above seven points, written to the medical
professional who will be
responsible for the patient’s endocrine treatments is sufficient.
Two-Letters are Generally Required for Surgery. It is ideal if mental health
professionals
conduct their tasks and periodically report on these processes to a team of
other mental health
professionals and nonpsychiatric physicians. Letters of recommendation to
physicians or
surgeons written after discussion with a gender team then reflect the
influence of the entire team.
One letter to the physician performing surgery will generally suffice as
long as it is signed by
two mental health professionals.
More commonly, however, letters of recommendation are from mental health
professionals who work alone without colleagues experienced with gender
identity disorders.
Because professionals working independently may not have the benefit of
ongoing professional
consultation on gender cases, two letters of recommendation are required
prior to initiating
hormonal therapy or surgery. If the first letter is from a person with a
master's degree, the second letter should be from a psychiatrist or a clinical psychologist--those with
doctoral degrees who
can be expected to adequately evaluate co-morbid psychiatric conditions. If
the first letter is
from the patient's psychotherapist, the second letter should be from a
person who has only played
an evaluative role for the patient. Each letter writer, however, is expected
to cover the same
topics. At least one of the letters should be an extensive report. The
second letter writer, having
read the first letter, may choose to offer a briefer summary and an
agreement with the
recommendation.
[Back to Top]
IV. TREATMENT OF CHILDREN
The initial task of the child-specialist mental health professional is to
provide careful
diagnostic assessments of gender-disturbed children. This means that the
individual child's
gender identity and gender role behaviors, family dynamics, past traumatic
experiences, and
general psychological health are separately assessed. Gender-disturbed
children differ
significantly along these parameters. Since many gender-disturbed children
do not meet formal
criteria for GID of Childhood and many that do will not continue to do so
later in childhood,
hormonal and surgical therapies should never be undertaken with this age
group. Treatment for
these children, however, should be offered based on the clinician's
assessment. Over time, this
may involve family therapy, marital therapy, parent guidance, individual
therapy of the child, or
various combinations. Treatment should be extended to all forms of
psychopathology, not
simply the gender disturbance. Effort should be made, even with mild forms
of gender identity
struggles, to follow the family. This allows the child and the family to
benefit from continuing
services as the gender identity problem evolves and allows the clinician to
rethink the validity of
the initial assessment.
[Back to Top]
V. TREATMENT OF ADOLESCENTS
Adolescents should be dealt with conservatively because gender identity
development can
rapidly and unexpectedly evolve. They should be followed, provided
psychotherapeutic support,
educated about gender options, and encouraged to pay attention to other
aspects of their social,
intellectual, vocational, and interpersonal development. Because an
adolescent shift toward
gender conformity can occur primarily to please the family, it may not
persist or reflect a
permanent change in gender identity. Clinical follow-up is encouraged.
Adolescents may be eligible for beginning triadic therapy as early as age
18, preferably
with parental consent. Parental consent presumes a good working relationship
between the
mental health professional and the parents, so that they, too, fully
understand the nature of the
GID. In many European countries 16 to18 year-olds are legal adults for
medical decision-making,
and do not require parental consent.
The age at which adolescents who consistently maintain an unwavering desire
to live
permanently in the opposite gender role should be permitted to begin the
real life experience or
hormonal therapy is 18 years.
Hormonal Therapy for Adolescents. Hormonal treatment should be conducted in
two phases
only after puberty is well established. In the initial phase biological
males should be provided an
antiandrogen (which neutralize testosterone effects only) or an LHRH agonist
(which stops the
production of testosterone only), and biological females should be
administered sufficient
androgens, progestins, or LHRH agonists (which stops the production of
estradiol, estrogen, and
progesterone) to stop menstruation. After these changes have occurred and
the adolescent's
mental health remains stable, biologic males may be given estrogenic agents
and biologic
females may be given higher masculinizing doses of androgens. Medications
used in the second phase, estrogenic agents for biologic males and high dose androgens for
biologic females,
produce irreversible changes.
Prior to Age 18. In selected cases, the real life experience can begin at
age 16, with or
without first phase hormones.
The administration of hormones to adolescents younger than age 18 should
rarely be
done. These first phase therapies to delay the somatic changes of puberty
are best carried out in
specialized treatment centers under supervision of, or in consultation with,
an endocrinologist,
and preferably, a pediatric endocrinologist, who is part of an
interdisciplinary team. Two goals
justify this intervention: a) to gain time to further explore the gender and
other developmental
issues in psychotherapy; b) make passing easier if the adolescent continues
to pursue gender
change.
In order to provide puberty delaying hormones to a person less than
age 18, the
following criteria must be met:
(1) throughout childhood they have demonstrated an intense pattern of
cross-gender identity
and aversion to expected gender role behaviors;
(2) gender discomfort has significantly increased with the onset of puberty;
(3) their social, intellectual, psychological, and interpersonal development
are limited as a
consequence of their GID;
(4) serious psychopathology, except as a consequence of the GID, is absent;
(5) the family consents and participates in the triadic therapy.
Prior to Age 16. Second phase hormones–those which induce opposite sex body
should not be
given prior to age 16 years.
Mental Health Professional Involvement is an Eligibility Requirement for
Triadic Therapy
During Adolescence. To be eligible for the implementation of the real life
experience or
hormone therapy, the mental health professional should be involved with the
patient and family
for a minimum of six months. To be eligible for the recommendation of
genital reconstructive
surgery or mastectomy, the mental health professional should be integrally
involved with the
adolescent and the family for at least eighteen months. While the number of
sessions during
these six and eighteen month periods rests upon the clinician's judgment,
the intent is that
hormones and surgery be thoughtfully and recurrently considered over time.
School-aged persons with gender identity disorders often are so
uncomfortable due to
negative peer interactions and a felt incapacity to participate in the roles
of their biologic sex that
they refuse to attend school. Mental health professionals should be prepared
to work
collaboratively with school personnel to find ways to continue the
educational and social
development of their patients.
[Back to Top]
VI. PSYCHOTHERAPY WITH ADULTS
A Basic Observation. Many adults with gender identity disorder find
comfortable, effective
ways of identifying themselves that do not involve all the components of the
triadic treatment
sequence. While some individuals manage to do this on their own,
psychotherapy can be very
helpful in bringing about the discovery and maturational processes that
enable self-comfort.
Psychotherapy is Not an Absolute Requirement for Triadic Therapy.
Every
adult gender
patient does not require psychotherapy in order to precede with the real
life experience,
hormones, or surgery. Individual programs vary to the extent that they
perceive the need for
psychotherapy. When the mental health professional's initial assessment
leads to a
recommendation for psychotherapy, the clinician should specify the goals of
treatment, estimate
its frequency and duration. The SOC committee is wary of insistence on some
minimum number
of psychotherapy sessions prior to the real life experience, hormones, or
surgery for three
reasons: 1.) patients differ widely in their abilities to attain similar
goals in a specified time; 2.)
minimum number of sessions tend to be construed as a hurdle which tends to
be devoid of the
genuine opportunity for personal growth; 3.) the committee would like to
encourage the use of
the mental health professional as an important support to the patient
throughout all phases of
gender transition. Individual programs may set eligibility criteria to some
minimum number of
sessions or months of psychotherapy.
The mental health professional who conducts the initial evaluation need not
be the
psychotherapist. If psychotherapy is not done by members of a gender team,
the psychotherapist
should be informed that a letter describing the patient's therapy may be
requested so the patient
can proceed with the next phase of rehabilitation.
Goals of Psychotherapy. Psychotherapy often provides education about a range
of options not
previously seriously considered by the patient. It emphasizes the need to
set realistic life goals
for work and relationships. And it seeks to define and alleviate the
patient's conflicts that may
have undermined a stable lifestyle.
The Therapeutic Relationship. The establishment of a reliable trusting
relationship with
the patient is the first step toward successful work as a mental health
professional. This is usually
accomplished by competent nonjudgmental exploration of the gender issue with
the patient
during the initial diagnostic evaluation. Other issues may be better dealt
with later, after the
person feels that the clinician is interested in and understands the gender
problem. Ideally, the
clinician's work is with the whole of the person's complexity, not merely a
narrow definition of
gender. The goal of therapy, to help the person to live more comfortably
with in a gender role
and body, also means to deal effectively with nongender issues. The
clinician often attempts to
facilitate the capacity to work and to establish or maintain supportive
relationships. The clinician
understands a broader definition of gender--an aspect of identity that is
inextricably related to all
aspects of living. Even when these initial goals are attained, mental health
professionals should
discuss the likelihood that no educational, psychotherapeutic, medical, or
surgical therapy can
permanently eradicate all vestiges of the person's original sex assignment.
Processes of Psychotherapy. Psychotherapy is a series of highly refined
interactive
communications between a person who is knowledgeable about how people
emotionally suffer
and how this may be alleviated and one who is experiencing gender distress.
The psychotherapy
sessions initiate a developmental process. They enable the person's: history
to be appreciated,
current dilemmas to be understood, and unrealistic ideas and maladaptive
behaviors to be
identified. Psychotherapy is not a specific technology, informed by a
specific ideology, delivered
to the patient to cure the gender identity disorder. Its usual goal is a
long-term stable life style
with realistic chances for success in relationships, education, work, and
gender identity and role.
Gender distress often intensifies relationship, work, and educational
dilemmas. Typically,
psychotherapy consists regularly held 50-minute sessions.
The therapist should make clear that it is the patient's right to choose
among many
options. The patient can experiment over time with alternative approaches.
Since most patients
have tried unsuccessfully to suppress their cross-gender aspirations prior
to seeing the
psychotherapist, this recommendation is not realistic.
Ideally, psychotherapy is a collaborative effort. The therapist must be
certain that the
patient understands the concepts of eligibility and readiness because they
must cooperate in
defining the patient's problems and in assessing progress in dealing with
them. Collaboration
prevents stalemates between a therapist who seems needlessly withholding of
a recommendation
and a patient who seems too profoundly distrusting to freely share thoughts,
feelings, events, and
relationship.
Benefit from psychotherapy may be attained at every stage of gender
evolution. This
includes the post-surgical period when the anatomic obstacles to gender
comfort have been
removed and the person continues to feel a lack of genuine comfort and skill
in living in the new
gender role.
Options for Gender Adaptation. The activities and processes that are listed
below have, in
various combinations, helped people to find more personal ease. These
adaptations may evolve
spontaneously and during psychotherapy. Finding a new adequate gender
adaptation does not
mean that the person may not in the future elect to pursue the real life
experience, hormones, and
genital reconstruction. These activities and processes are focused on
matters other than real life
experience, hormones, and surgery.
Activities-
Biological Males
1. cross-dressing: unobtrusively with undergarments; unisexually; or in a
feminine fashion
2. changing the body through: hair removal through electrolysis or body
waxing; minor
plastic cosmetic surgical procedures
3. increasing grooming, wardrobe, and vocal expression skills
Biological Females
1. cross-dressing: unobtrusively with undergarments, unisexually, or in a
masculine fashion
2. changing the body through breast binding, weight lifting, applying
theatrical facial hair
3. padding underpants or wearing a penile prosthesis
Both genders
1. learning about transgender phenomena from: support groups and gender
networks; communication with peers via the Internet; studying these
Standards of
Care; relevant lay and professional literatures about legal rights
pertaining to work,
relationships, and public cross-dressing
2. involvement in recreational activities of the desired gender
3. episodic cross-gender living
Processes
1. acceptance of personal homosexual or bisexual fantasies and behaviors
(orientation)
as distinct from gender role aspirations
2. acceptance of the need to maintain a job, provide for the emotional needs
of children,
honor a spousal commitment, or not to distress a family member as currently
having
a higher priority than the personal wish for constant cross-gender
expression
3. integration of male and female gender awareness into daily living
4. identification of the triggers for increased cross-gender yearnings and
effectively
attend to them; for instance, develop better self-protective,
self-assertive, and
vocational skills to advance at work and resolve interpersonal struggles to
strengthen
key relationships
5. seeking spiritual comfort
[Back to Top]
VII. THE REAL-LIFE EXPERIENCE
The act of fully adopting a new or evolving gender role for the events and
processes
of everyday life is known as the real-life experience. The real-life
experience is essential to
the transition process to the gender role that confirms with personal gender
identity. Since
changing one's gender role has immediate profound personal and social
consequences, the
decision to do so should be preceded by an awareness of what the familial,
vocational,
interpersonal, educational, economic, and legal consequences are likely to
be. Professionals
have a responsibility to discuss these predictable consequences. These
represent external
reality issues that must be confronted for success in the new gender role.
This may be quite
different from the personal happiness in the new gender role that was
imagined prior to the
real life experience.
Parameters of the Real Life Experience. When clinicians assess the quality
of a person's
real-life experience in the new gender role, the following abilities are
reviewed:
1. to maintain full or part-time employment
2. to function as a student;
3. to function in community-based volunteer activity;
4. to undertake some combination of items 1-3
5. to acquire a new (legal) first or last name
6. to provide documentation that persons other than the therapist know that
the patient
functions in the new gender role.
Real-Life Experience versus Real Life Test. Although professionals may
recommend
living in the desired gender as a step toward surgical assistance, the
decision as to when and
how to begin the real-life experience remains the person's responsibility.
Some begin the
real-life experience and decide that this often imagined life direction is
not in their best
interest. Professionals sometimes construe the real-life experience as the
real life test of the
ultimate diagnosis. If patients prospered in the aspired-to gender, they
were confirmed as
"transsexual," if they decided against continuing, they "must not have
been." This reasoning
is a confusion of the forces that enable successful adaptation with the
presence of a gender
identity disorder. The real-life experience tests the person's resolve,
capacity to function in
the aspired to gender, and the alignment of social, economic, and
psychological supports. It
assists both the patient and the mental health professional in their
judgments how to proceed.
Diagnosis, although always open for reconsideration, precedes a
recommendation for
patients to embark on the real life experience. When the patient is
successful in the real life
experience, both the MHP and the patient gain confidence in the original
decision to embark
on the path to the irreversible further steps.
Beard Removal for the Male to Female Patient. Beard density is a genetically
determined
secondary sex characteristic whose growth is not significantly slowed by
cross-sex hormone
administration. Facial hair removal via electrolysis is a generally safe,
time-consuming
process that often facilitates the real life experience for biologic males.
Side effects are often
discomfort during and immediately after the procedure, and, less frequently,
hypo-or hyper
pigmentation, scarring, and folliculitis. Formal medical approval for hair
removal is not
necessary; electrolysis may be begun whenever the patient deems it prudent.
It is usually
recommended prior to commencing the real life experience because the beard
must be grown
out to visible lengths so that it can be most easily removed. Many patients
will require two
years of regular treatments to effectively eradicate their facial hair. Hair
removal by laser is a
new alternative approach, but experience with it is limited.
[Back to Top]
VIII. REQUIREMENTS FOR HORMONE THERAPY
FOR ADULTS
Eligibility Criteria. The administration of hormones is not to be lightly
undertaken because of
their medical and social dangers. Three criteria exist.
1. age 18 years
2. demonstrable knowledge of what hormones medically can and cannot do and
their social
benefits and risks;
3. Either a documented real life experience should be undertaken for at
least three months prior
to the administration of hormones Or
4. A period of psychotherapy of a duration specified by the mental health
professional after the
initial evaluation (usually a minimum of three months) should be undertaken
5. Under no circumstances should a person be provided hormones who has
neither fulfilled
criteria #3 or #4.
Readiness Criteria. Three criteria exist:
1. the patient has had further consolidation of gender identity during the
real-life experience
or psychotherapy;
2. the patient has made some progress in mastering other identified problems
leading to
improving or continuing stable mental health (this implies an absence of
problems such as
sociopathy, substance abuse, psychosis, suicidality, for instance);
3. hormones are likely to be taken in a responsible manner.
Can Hormones Be Given For Those Who Do Not Initially Want Surgery or a Real
Life
Experience? Yes, but after diagnosis and psychotherapy with a qualified
mental health
professional following minimal standards listed above. These cases often are
deeply
controversial and require particular caution.
[Back to Top]
IX. HORMONE THERAPY FOR ADULTS
Reasons for Hormone Therapy. Cross-sex hormonal treatments play an important
role in the
anatomical and psychological gender transition process for properly selected
adults with gender
identity disorders. These hormones are medically necessary for
rehabilitation in the new gender.
They improve the quality of life and limit psychiatric co-morbidity which
often accompanies
lack of treatment. When physicians administer androgens to biologic females
and estrogens,
progesterone, and/or testosterone-blocking agents to biologic males,
patients feel and appear
more like members of their aspired-to sex.
The Desired Effects of Hormones. Biologic males treated with cross-sex
hormones can
realistically expect treatment to result in: breast growth, some
redistribution of body fat to
approximate a female body habitus, decreased upper body strength, softening
of skin, decrease in
body hair, slowing or stopping the loss of scalp hair, decreased fertility
and testicular size, and
less frequent, less firm erections. Most of these changes are reversible,
although breast
enlargement will not completely reverse after discontinuation of treatment.
Biologic females treated with cross-sex hormones can expect: a permanent
deepening of the
voice, permanent clitoral enlargement, mild breast atrophy, increased upper
body strength,
weight gain, facial and body hair growth, male-pattern baldness, increased
social and sexual
interest and arousability, and decreased hip fat.
The degree of desired effects actually attained varies from patient to
patient. The maximum
physical effects of hormones may not be evident until two years of
continuous treatment. Heredity limits the tissue response to hormones and cannot be overcome by
increasing dosage.
Medical Side Effects. Side effects in biologic males treated with estrogens
may include
increased propensity to blood clotting (venous thrombosis with a risk of
fatal pulmonary
embolism), development of benign pituitary prolactinomas, infertility,
weight gain, emotional
lability and liver disease. Side effects in biologic females treated with
testosterone may include
infertility, acne, emotional lability (including the potential for major
depression), increases in
sexual desire, shift of lipid profiles to male patterns which increase the
risk of cardiovascular
disease, and the potential to develop benign and malignant liver tumors and
hepatic dysfunction.
Patients with medical problems or otherwise at risk for cardiovascular
disease may be more
likely to experience serious or fatal consequences of cross-sex hormonal
treatments. For
example, cigarette smoking, obesity, advanced age, heart disease,
hypertension, clotting
abnormalities, malignancy, and some endocrine abnormalities are relative
contraindications for
the use of hormonal treatment. Therefore, some patients may not be able to
tolerate cross-sex
hormones. However, risk-benefit ratios should be considered collaboratively
between the patient
and prescribing physician.
Social Side Effects. There are often important social effects from taking
hormones which the
patient must consider. These include relationship changes with family
members, friends, and
employers. Hormone use may be an important factor in job discrimination,
loss of employment,
divorce and marriage decisions, and the restriction or loss of visitation
rights for children. The
social effects of hormones, however, can be positive as well.
The Prescribing Physician's Responsibilities. Hormones are to be prescribed
by a physician.
Hormones are not to be administered simply because patients demand them.
Adequate
psychological and medical assessment are required before and during
treatment. Patients who do
not understand the eligibility and readiness requirements and who are
unaware of the SOC
should be informed of them. This may be a good indication for a referral to
a mental health
professional experienced with gender identity disorders.
The physician providing hormonal treatment and medical monitoring need not
be a specialist
in endocrinology, but should become well-versed in the relevant medical and
psychological
aspects of treating persons with gender identity disorders.
After a thorough medical history, physical examination, and laboratory
examination, the
physician should again review the likely effects and side effects of this
treatment, including the
potential for serious, life-threatening consequences. The patient must have
the cognitive capacity
to appreciate the risks and benefits of treatment, have his/her questions
answered, and agree to
medical monitoring of treatment. The medical record must contain a written
informed consent
document reflecting a discussion of the risks and benefits of hormone
therapy.
Physicians have a wide latitude in what hormone preparations they may
prescribe and what
routes of administration they may select for individual patients. As
therapeutic options rapidly
evolve, it is the responsibility of the prescribing physician to make these
decisions. Viable
options include oral, injectable, and transdermal delivery systems.
Topically applied hormonal
creams have not been shown to produce adequate cross-sex effects. The use of transdermal
estrogen patches should be considered for males over 40 years of age or
those with clotting
abnormalities or a history of venous thrombosis.
In the absence of any other medical, surgical, or psychiatric conditions,
basic medical
monitoring should include: serial physical examinations relevant to
treatment effects and side
effects, vital sign measurements before and during treatment, weight
measurements, and laboratory assessment. For those receiving estrogens, the minimum laboratory
assessment
should consist of a pretreatment free testosterone level, fasting glucose,
liver function tests, and
complete blood count with reassessment at 6 and 12 months and annually
thereafter. A
pretreatment prolactin level should be obtained and repeated at 1, 2, and 3
years. If
hyperprolactemia does not occur during this time, no further measurements
are necessary.
For those receiving androgens, the minimum laboratory assessment should
consist of
pretreatment liver function tests and complete blood count with reassessment
at 6 months, 12
months, and yearly thereafter. Yearly palpation of the liver should be
considered. Patients should
be screened for glucose intolerance and gall bladder disease.
Biological males undergoing estrogen treatment should be monitored for
breast cancer
and encourage in engage in routine self-examination. As they age, they
should be monitored for
prostatic cancer. Females who have undergone mastectomies who have a family
history of
breast cancer should be monitored for the disease.
Gender patients, whether
on hormones or not,
should be screened for pelvic malignancies as are other persons.
Physicians should provide their patients with a brief written statement
indicating that this
person is under medical supervision which includes cross-sex hormone
therapy. During the early
phases of hormone treatment, the patient should be encouraged to carry this
statement at all times
to help prevent difficulties with the police.
Reductions in Hormone Doses After Gonadectomy. Estrogen doses in
post-orchiectomy
patients can often be reduced by 1/3 to ˝ and still maintain feminization.
Reductions in
testosterone doses post-oophorectomy should be considered, taking into
account the risks of
osteoporosis. Lifelong maintenance treatment is usually required in both
sexes.
The Misuse of Hormones. Some individuals obtain hormones from nonmedical
sources,
such as friends, family members, and pharmacies in other countries. These
treatments are often
excessive in dose, produce more side effects, are medically unmonitored, and
expose the person
to greater medical risk. Persons taking medically monitored hormones have
been known to take
additional doses of illicitly obtained hormones without their physician's
knowledge. Mental
health professionals and prescribing physicians should inquire whether their
patients have
increased their doses and make a reasonable effort to enhance compliance in
order to limit
medical and psychiatric morbidity from treatment. It is ethical for
physicians to discontinue
taking medical and legal responsibility for patients who place themselves at
higher risk by
noncompliance with the prescribed hormonal regimen. Patient pressure is not
a sufficient reason
to deliver substandard medical care.
Other Potential Benefits of Hormones. Hormonal treatment, when medically
tolerated,
should precede any genital surgical interventions. Satisfaction with the
hormone's effects
consolidates the person's identity as a member of the aspired-to gender and
further adds to the
conviction to proceed. Dissatisfaction with hormonal effects may signal
ambivalence about
proceeding to surgical interventions. Hormones alone often generate adequate
breast
development, precluding the need for augmentation mammaplasty. Some patients
who receive
hormonal treatment will not desire surgical interventions.
The Use of Antiandrogens and Sequential Therapy. Antiandrogens can be used
as adjunctive
treatments in biologic males receiving estrogens, even though they are not
always necessary to
achieve feminization. In some patients, antiandrogens may offer assistance
by more profoundly
suppressing the production of testosterone and enabling a lower dose of
estrogen to be used when
adverse estrogen side effects are anticipated.
Feminization does not require sequential therapy. Attempts to mimic the
menstrual cycle
by prescribing interrupted estrogen therapy or substituting progesterone for
estrogen during part
of the month are not necessary to achieve feminization.
Informed Consent. Hormonal treatments should be provided only to those who
are legally able
to provide informed consent. This includes persons who have been declared by
a court to be
emancipated minors and incarcerated persons who are considered competent to
participate in
their
medical decisions. For adolescents, informed consent needs to include the
minor patient's assent
and the written informed consent of a parent or legal guardian. Informed
consent implies that the
patient understands that hormone administration limits fertility and the
removal of sexual organs
prevents the capacity to reproduce.
Hormonal Treatment of Prisoners. Patients who are receiving hormonal
treatments as part of a
medically monitored program of gender transition should continue to receive
such treatment
while incarcerated to prevent emotional lability, reversibility of physical
effects, and the sense of
desperation that may include depression and suicidality.
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X.
REQUIREMENTS FOR GENITAL RECONSTRUCTIVE AND BREAST SURGERY
Eligibility Criteria. These minimum eligibility criteria for various
surgeries equally apply to
biological males seeking genital reconstruction and biological females
seeking mastectomy and
phalloplasty. They are:
1. legal age of majority in the patient's nation
2. 12 months of continuous hormonal therapy for those without a medical
contraindication
3. 12 months of successful continuous full time real-life experience.
Periods of returning to
the original gender may indicate ambivalence about proceeding and should not
be used to
fulfill this criterion
4. if required by the mental health professional, regular responsible
participation in a
psychotherapy throughout the real life experience at a frequency determined
by the mental
health professional. Psychotherapy, per se, is not an absolute eligibility
criterion for surgery.
5. demonstrable knowledge of the cost, required lengths of hospitalizations,
likely
complications, and post surgical rehabilitation requirements of various
surgical approaches.
6. awareness of different competent surgeons.
Readiness Criteria. The readiness
criteria include:
1. demonstrable progress in consolidating the evolving gender identity
2. demonstrable progress in dealing with work, family, and interpersonal
issues resulting in a
significantly better state of mental health (this implies an absence of
problems such as
sociopathy, substance abuse, psychosis, suicidality, for instance).
Can Surgery Be Provided Without Hormones and the Real Life Experience?
Individuals
who "just" want mastectomy, penectomy, or genital reconstructive therapy
without meeting the
eligibility criteria can not be provided bodily alterations because they are
"special cases." Organ
removal or remodeling is a surgical treatment for a gender disorder. The
surgery occurs after
many careful steps. Such surgery is not a patient right that once demanded
has to be granted.
The SOC contains provisions for an individual approach for every patient,
but this does not mean
that the general guidelines for the sequence of psychiatric evaluation,
possible psychotherapy,
hormones, and real life experience can be ignored because a person desires
just one surgical
procedure.
If a person has lived convincingly as a member of the opposite sex for a
long period of
time and is assessed to be a psychologically healthy person after a
requisite period of
psychotherapy, there is no inherent reason that he or she must take hormones
prior to having a
desired breast or genital surgery.
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XI. SURGERY
Conditions under which Surgery May Occur. Surgical treatment for a person
with a gender
identity disorder is not merely another elective procedure. Typical elective
procedures only
involve a private mutually consenting contract between a suffering person
and a technically
competent surgeon. Surgeries for GID are to be undertaken only after a
comprehensive
evaluation by a qualified mental health professional. Surgery may be
performed once written
documentation testifies that a comprehensive evaluation has occurred and
that the person has met
the eligibility and readiness criteria. By following this procedure, the
mental health professional,
the physician prescribing hormones, the surgeon and the patient share in the
responsibility of the
decision to make irreversible changes to the body. The patient who has
decided to undergo
genital or breast operations, however, tends to view the surgery as the most
important and
effective treatment to correct the underlying problem.
Requirements for the Surgeon Performing Genital Reconstruction. The surgeon
should be a
urologist, gynecologist, plastic surgeon or general surgeon, and
Board-Certified as such by a
nationally known and reputable association. The surgeon should have
specialized competence in
genital reconstructive techniques as indicated by documented supervised
training with a more
experienced surgeon. Even experienced surgeons in this field must be willing
to have their
therapeutic skills reviewed by their peers. Willingness and cooperation with
peer review are
essential. This includes attendance at professional meetings where new ideas
about techniques
are presented.
Ideally, the surgeon should be knowledgeable about more than one of the
surgical
techniques for genital reconstruction so that the surgeon will be able to
choose the ideal
technique for the individual patient's anatomy and medical history. When
surgeons are skilled in
a single technique, they should so inform their patients and refer those who
do not want or are
unsuitable for this procedure to another surgeon.
Prior to performing any surgical procedures, the surgeon should have all
medical
conditions appropriately monitored and the effects of the hormonal treatment
upon the liver and
other organ systems investigated. This can be done alone or in conjunction
with medical
colleagues. Since pre-existing conditions may complicate genital
reconstructive surgeries,
surgeons must also be competent in urological diagnosis. The medical record
should contain
written informed consent for the particular surgery to be performed.
How to Deal with the Ethical Question Concerning Sex Reassignment (Gender
Confirming)
Surgeries. Many persons, including medical professionals, object on ethical
grounds to surgery
for GID. In ordinary surgical practice, pathological tissues are removed in
order to restore
disturbed functions or corrections are made to disfiguring body features to
improve the patient's
self image. These specific conditions are not present when surgery is
performed for gender
identity disorders. In order to understand how surgery is able to alleviate
the psychological
discomfort of the patient with a gender identity disorder, professionals who
are inexperienced
with severe gender identity disorders need to listen to these patients
discuss their symptoms,
dilemmas, and life histories. It is important that the professionals dealing
with gender patients
feel comfortable about altering anatomically normal structures.
The resistance against performing surgery on the ethical bases of "above all
do no harm"
should be respected, discussed, and met with the opportunity to learn about
the psychological
distress of having a gender identity disorder from the patients themselves.
Genital, Breast, and Other Surgery for the Male to Female Patient. Surgical
procedures may
include orchiectomy, penectomy, vaginoplasty and augmentation mammaplasty.
Vaginoplasty
requires both skilled surgery and postoperative treatment. The three
techniques are: penile skin
inversion, pedicled rectosigmoid transplant, or free skin graft to line the
neovagina.
Augmentation mammaplasty may be performed prior to vaginoplasty if the
physician prescribing
hormones and the surgeon have documented that breast enlargement after
undergoing hormonal
treatment for two years is not sufficient for comfort in the social gender
role. Other surgeries that
may be performed to assist feminization include: reduction thyroid
chondroplasty, suction assisted
lipoplasty of the waist, rhinoplasty, facial bone reduction, face-lift, and
blephoroplasty.
These do not require letters of recommendation from mental health
professionals as does genital
reconstruction therapy. The committee is concerned about the safety and
effectiveness of voice
modification surgery and urges more follow-up research prior to widespread
use of this
procedure. Patients who elect this procedure should do so after all other
surgeries requiring
general anesthesia with intubation are completed to protect their vocal
cords.
Breast and Genital Surgery for the Female to Male Patient. Surgical
procedures may include
mastectomy (chest reconstruction), hysterectomy, salpingo-oophorectomy,
vaginectomy,
metoidioplasty, scrotoplasty, urethroplasty, and phalloplasty. Current
operative techniques for
phalloplasty are varied. The choice of techniques may be restricted by
anatomical or surgical
considerations. If the objectives of phalloplasty are a neophallus of good
appearance, standing
micturition, sexual sensation, and/or coital ability, the patient should be
clearly informed that
there are both several separate stages of surgery and frequent technical
difficulties which require
additional operations. Even the metoidioplasty technique, which in theory is
a one-stage
procedure for construction of a microphallus, often requires more than one
surgery. The plethora
of techniques for penis construction indicate that further technical
development is necessary.
Patients may undergo hysterectomy and salpingo-oophorectomy
prior to phalloplasty.
The mastectomy procedure is usually the first surgery performed for ease in
passing in the
preferred gender role, but for some patients it is the only surgery
undertaken. When the amount
of breast tissue removed requires skin removal, a scar will result and the
patient is informed.
Genital surgeries often combine more than one of the above operations, but
typically
genital surgery requires several separate operative procedures.
The Surgeon's Relationship with the Physician Prescribing Hormones and
Mental Health
Professional. The surgeon is not merely an interchangeable technician hired
to perform a
procedure. The surgeon is part of the team of clinicians participating in a
long rehabilitation
process. The patient often feels an immense positive regard for
(transference) and trusting bond
to the surgeon, which ideally will enable long-term follow-up care. Because
of the significance of
the surgeon to the patient, these physicians are responsible for awareness
of the diagnosis that has
led to the recommendation for genital reconstruction. Surgeons should have a
chance to speak at
length with their patients to satisfy themselves that the patient is likely
to benefit from the
procedures apart from the letters recommending surgery. Ideally, the surgeon
should have a close
working relationship with the other professionals who have been actively
involved in the patient's
psychological and endocrinological care. This is usually best accomplished
by belonging to an
interdisciplinary team of professionals who specialize in gender identity
disorders. Such gender
teams do not exist everywhere, however. At the very least, the surgeon needs
to be reassured that
the mental health professional and physician prescribing hormones are
reputable professionals
with specialized experience with the gender identity disorders. This is
often reflected in the
quality of the documentation letters. Since factitious and falsified letters
have occasionally been
presented, surgeons should personally communicate with at least one of the
mental health
professionals to verify the authenticity of their letters.
Surgery for Persons with Psychotic Conditions and Other Serious Mental
Illnesses.
Surgical therapies are undertaken only for the treatment of the patient's
gender identity disorder.
When severe psychiatric disorders with impaired reality testing--such as,
schizophrenia,
dissociative identity disorder, borderline personality disorder, are present
as well, a significant
effort must be made to improve these conditions with state-of-the-art
psychiatric treatments
before hormones and surgery are contemplated. A reevaluation by a Ph.D
clinical psychologist or
psychiatrist should be conducted within two weeks of surgery describing the
patient's mental
status and readiness for surgery. It is preferable if the clinician has
previously evaluated the
patient. No surgery should be performed while the patient is actively
psychotic.
Post surgical Follow-up by Professionals. In general, long-term
postoperative follow-up is
encouraging in that it is one of the factors associated with a good
psychosocial outcome. Follow-up
is also essential to the patient's subsequent anatomic and medical health
and to the surgeon's
knowledge about the benefits and limitations of surgery.
Long-term follow-up with the surgeon is recommended in all patients to
ensure an
optimal surgical outcome. Surgeons who are operating on patients who are
coming from long
distances should include personal follow-up in their care plan and then
ensure affordable, local,
long-term aftercare in the patient's geographic region. Postoperative
patients may also
incorrectly exclude themselves from follow-up with the physician prescribing
hormones, not
recognizing that these physicians are best able to prevent, diagnose and
treat possible long term
medical conditions that are unique to the hormonally and surgically treated.
Postoperative
patients also have general health concerns and should undergo regular
medical screening
according to recommended guidelines.
The need for follow-up extends beyond the endocrinologist and surgeon,
however, to the
mental health professional, who having spent a longer period of time with
the patient than any
other professional, is in an excellent position to assist in any
post-operative adjustment
difficulties.
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Productions, Lehigh Valley, PA.