Standards
Of Care For Gender Identity Disorders - Fifth Version (June 15, 1998)
***
|
-
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. |
***
| 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 1960sand 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 cross-dressing, 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 cross-gender
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 subclassification 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. |
***
***
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 |
***
***
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. |
***
| 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 non-psychiatric 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. |
***
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. |
***
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, estrone, and progesterone) to stop menstruation. After these
changes have occurred and the adolescent's mental health remains stable,
biologic males maybe 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 -
***
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. |
***
| 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 procede 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. |
***
***
***
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. |
***
***
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. |
***
***
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. |
***
***
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. |
***
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. |
***
| 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. |
***
| 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 at1, 2, and 3 years. If hyperprolactinemia
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 -
***
Estrogendoses in post-orchiectomy
patients can often be reduced by 1/3 to 1/2 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. |
***
| 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. |
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 blepharoplasty.
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. |
***
Postsurgical
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. |
***
|
|
|
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. |
***
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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 |
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