Standards
Of Care For Gender Identity Disorders - Fifth Version (June 15, 1998)
***
|
-
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 withindividuals ||||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 theDSM-IV/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 nonpsychiatric
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 becausegender 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, estrone, 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
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.
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. |
***
***
| 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 blepharoplasty. |
***
| 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.
Postsurgical 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. |
***
|
|
|
Notes
On The Standards Of Care
***
The
Standards of Care are provided on this site for informational purposes
only -
***
The Standards of Care are intended
for use as guidelines, designed to promote the health and welfare of persons
with gender identity disorders, and exist for the protection of both the
patient and the theraputic provider of such treatment. As such, they are
not cast in stone but rather open to interpretation on a case by case basis
between the patient and the treatment professional involved, both should
be aware of these guidelines and the treatment standards they are designed
to maintain. |
***
| The
Standards of Care are created and maintained by - |
***
The
Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA)
1300 South Second Street, Suite 180
Minneapolis, MN 55454 USA
(612) 625-1500
http://www.hbigda.org/ |
***
These
standards are updated and revised as new scientific information becomes
available -
***
The current edition of the Standards
of Care presented here was released in 1998, and is the fifth version
since the original 1979 document. Previous revisions were in 1980, 1981,
and 1990. The Standards are now undergoing another major revision, with
a new edition (Version Six) expected in early 2001. We will update this
information as soon as the new version becomes available to us. |
***
|
|
|
Forums
Contributions
|
While all of our site is open to your contributions and suggestions, the
forums area in particular depends upon them. If this area is to become
the source for information and support that we know it can be, then it
is all of our transgendered sisters & brothers that will make it so.
Your input might be just what someone else needed! If you have something
to share here E-mail us: TGE@tg2tg.org |
|
|
|
|
|
