WPATH Standards of Care- Version 1

The hormonal and surgical sex reassignment of gender dysphoric persons

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Prepared by: The founding committee of the Harry Benjamin International Gender Dysphoria Association. Jack C. Berger, M. D. Richard Green, M. D., Donald R. Laub, M. D., Charles L. Reynolds, Jr. M. D., Paul A. Walker, Ph. D. (Chairperson), Leo Wollman, M. D.

Distributed by: The Janus Information Facility. The University of Texas Medical Branch Galveston, Texas 77550

Photo by Arisa Chattasa on Unsplash

Introduction

As of the beginning of 1979, an undocumentable estimate of the number of adult Americans hormonally and surgically sex-reassigned ranges from 3,000 to 6,000. Also undocumentable is the estimate that between 30,000 and 60,000 persons, worldwide, consider themselves to be valid candidates for sex-reassignment. As of mid-1978, approximately 40 centers in the Western hemisphere offered surgical sex-reassignment to persons having a multiplicity of behavioral diagnoses applied under a multiplicity of criteria.

In recent decades, the demand for sex-reassignment has increased as have the number and variety of possible psychologic, hormonal and surgical treatments. rationale upon which such treatments are offered have become more and more complex. Varied philosophies of appropriate care have been suggested by various professionals identified as experts on the topic of gender identity. However, until the present, no statement on the standard of care to be offered to gender dysphoric patients (sex reassignment applicants) has received official sanction by any identifiable professional group. The present document is designed to fill that void.

Statement of Purpose

The Harry Benjamin International Gender Dysphoria Association presents the following as its explicit statement on the appropriate standards of care to be offered to applicants for hormonal and surgical sex reassignment.

Definitions

3.1 Standard of care. The standards of care, as listed below, are minimal requirements and are not to be construed as optimal standards of care. It is recommended that professionals involved in the management of sex-reassignment cases use the following as minimal criteria for the evaluation of their work. It should be noted that some experts on gender identity recommend that the time parameters listed below should be doubled, or tripled.

3.2 Hormonal sex-reassignment. Hormonal sex-reassignment refers to the administration of androgens to genotypic and phenotypic females, and the administration of estrogens and/or progesterones to genotypic and phenotypic males, for the purpose of effecting somatic changes in order for the patient to more closely approximate the physical appearance of the genotypically other sex. Hormonal sex-reassignment does not refer to the administration of hormones for the purpose of medical care and/or research conducted for the treatment or study of non- gender dysphoric medical conditions (e.g., aplastic anemia, impotence, cancer, etc.).

3.3 Surgical sex-reassignment refers to surgery of the genitalia and/or breasts performed for the purpose of altering the morphology in order to approximate the physical appearance of the genetically-other sex in persons diagnosed as gender dysphoric. Such surgical procedures as mastectomy, reduction mammoplasty, augmentation mammoplasty, castration, orchidectomy, penectomy, vaginoplasty, hysterectomy, salpingectomy, vaginectomy, oophorectomy and phalloplasty in the absence of any diagnosable birth defect or other medically defined pathology, except gender dysphoria, are included in this category labeled surgical sex-reassignment.

Surgical sex reassignment also refers to any and all other surgical procedures of non-genital or non-breast sites (nose, throat, chin, cheeks, hips, etc.) conducted for the purpose of effecting a more masculine appearance in a genetic female or for the purpose of effecting a more feminine appearance in a genetic male, in the absence of identifiable pathology which would warrant such surgery regardless of the patient's genetic sex (facial injuries, hermaphroditism, etc.)

3.4 Gender Dysphoria. Gender Dysphoria herein refers to that psychological state whereby a person demonstrates dissatisfaction with their sex of birth and the sex role, as socially defined, which applies to that sex, and who requests hormonal and surgical sex-reassignment. Gender dysphoria, herein, does not refer to cases of infant sex-reassignment or re-announcement nor does it refer to those persons who, although dissatisfied with their genetically and socially defined sex status (i.e., transvestites and transgenderists) usually do not request sex-reassignment. Gender dysphoria, therefore, is the primary working diagnosis applied to any and all persons requesting surgical and hormonal sex-reassignment.

Principles and standards

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

4.1.2. Principle 2. Hormonal and surgical sex reassignment are procedures requiring medical justification and are not of such minor consequence as to be performed on an elective basis.

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

4.1.4. Standard 1. Hormonal and/or surgical sex-reassignment on demand (i.e. justified simply because the patient has requested such procedures) is contraindicated. It is herein declared to be professionally improper to conduct, offer, administer or perform hormonal sex reassignment and/or surgical sex-reassignment without careful evaluation of the patient's reasons for requesting such services and evaluation of the beliefs and attitudes upon which such reasons are based.

4.2.1. Principle 4. The analysis or evaluation of reasons, motives, attitudes, purposes, etc., requires skills not usually associated with the professional training of persons other than psychiatrists and psychologists.

4.2.2. Principle 5. Hormonal and/or surgical sex reassignment is performed for the purpose of improving the quality of life as subsequently experienced and such experiences are most properly studied and evaluated by the behavioral scientist (psychiatrist or psychologist).

4.2.3. Principle 6. Hormonal and surgical sex-reassignment are usually offered to persons, in part, because a psychiatric/psychologic diagnosis of transsexualism (see DSM III, proposed, section 302.5X) some related diagnosis, has been made. Such diagnoses are properly made only by psychiatrists or psychologists.

4.2.4. Standard 2. Hormonal and surgical (genital and non-genital) sex-reassignment must be preceded by a firm recommendation for such procedures made by a certified and licensed psychiatrist or psychologist who can justify making such a recommendation by appeal to training or professional experience in dealing with sexual disorders, especially the disorders of gender identity and role.

4.3.1. Principle 7. The psychiatric/psychologic recommendation for hormonal and/or surgical sex-reassignment should, in part, be based upon an evaluation of how well the patient fits the diagnostic criteria for transsexualism, as listed in the DSM-III (proposed) category 302.5X to wit:

A. Persistent sense of discomfort and inappropriateness about one's anatomic sex.

B. Persistent wish to be rid of one's own genitals and to live as a member of the other sex.

C. The disturbance has been continuous (not limited to periods of stress) for at least two years.

D. Absence of physical intersex or genetic abnormality.

E. The disturbance is not symptomatic of another mental disorder, such as Schizophrenia.

This definition of transsexualism is herein interpreted not to exclude persons who meet the above criteria but who otherwise may, on the basis of their past behavioral histories, be conceptualized and classified as transvestites and/or effeminate male homosexuals or masculine female homosexuals.

4.3.2. Principle 8. The diagnostic evidence for "persistent" (see 4.3.1. A and 4.3.1 B, above) requires that the psychiatrist or psychologist have knowledge, independent of the patient's verbal claim, that the dysphoria, discomfort, sense of inappropriateness and wish to be rid of one's own genitals, have existed for at least two years. This evidence may be obtained by interview of the patient's appointed informant (friend or relative) or it may best be obtained by the fact that the psychiatrist or psychologist has personally known the patient for an extended period of time.

4.3.3. Standard 3. The psychiatrist or psychologist making the recommendation in favor of hormonal and non-genital (surgical) sex-reassignment shall have known the patient in a psychotherapeutic relationship, for at least 3 months prior to making said recommendation. The psychiatrist or psychologist making the recommendation in favor of genital (surgical) sex-reassignment shall have known the patient, in a psychotherapeutic relationship for at least 6 months prior to making said recommendation. That psychiatrist or psychologist should have access to the results of psychometric testing (including IQ testing of the patient) when such testing is clinically indicated.

4.4.1. Principle 9. Hormonal sex-reassignment is both therapeutic and diagnostic in that the patient requesting such therapy either reports satisfaction or dissatisfaction regarding the results of such therapy.

4.4.2. Principle 10. Hormonal sex-reassignment may have some irreversible effects (infertility, hair growth, voice deepening and clitoral enlargement in the female-to- male patient and infertility and breast growth in the male- to-female patient) and, therefore, such therapy must be offered only under the guidelines proposed in the present standards.

4.4.3. Principle 11. Hormonal sex-reassignment should precede surgical sex-reassignment as its effects (patient satisfaction or dissatisfaction) may indicate or contraindicate later surgical sex-reassignment.

4.4.4. Principle 12. The best indicator for hormonal and surgical sex-reassignment is how successfully the patient has been in living-out, full-time, vocationally and avocationally, in all social situations, the social role of the genetically other sex and how successfully the patient has been in being accepted by others as a member of that genetically other sex.

4.4.5. Standard 4. The initiation of hormonal sex-re- assignment shall be preceded by a period of at least 3 months during which time the patient lives full-time in the social role of the genetically other sex.

4.5.1. Standard 5. Non-genital sex-reassignment (facial, hip, limb, etc.) shall be preceded by a period of at least 6 months during which time the patient lives full-time in the social role of the genetically other sex.

4.6.1. Standard 6. Genital sex-reassignment shall be preceded by a period of at least 12 months during which time the patient lives full-time in the social role of the genetically other sex.

4.7.1. Principle 13. The intersexed patient (with a documented hormonal or genetic abnormality) should first be treated by procedures commonly accepted as appropriate for such medical conditions.

4.7.2. Principle 14. The patient having a psychiatric diagnosis (i.e., schizophrenia) in addition to a diagnosis of transsexualism should first be treated by procedures commonly accepted as appropriate for such non-transsexual psychiatric diagnoses.

4.7.3. Standard 7. Hormonal and surgical sex-reassignment may be made available to intersexed patients and to patients having non-transsexual psychiatric/psychologic diagnoses if the patient and therapist have fulfilled the requirements of the herein listed standards; if the patient can be reasonably expected to be habilitated or rehabilitated, in part, by such hormonal and surgical sex-reassignment procedures; and if all other commonly accepted therapeutic approaches to such intersexed or non- transsexual psychiatrically/psychologically diagnosed patients have been either attempted, or considered for use prior to the decision not to use such alternative therapies. The diagnosis of schizophrenia, therefore, does not necessarily preclude surgical and hormonal sex- reassignment.

4.8.1. Principle 15. Peer review is a commonly accepted procedure in most branches of science and is used primarily to ensure maximal efficiency and correctness of scientific decisions and procedures.

4.8.2. Principle 16. Psychiatrists and psychologists must often rely on possibly unreliable or invalid sources of information (patients' verbal reports or the verbal reports of the patients' families and friends) in making clinical decisions and in judging whether or not a patient has fulfilled the requirements of the herein listed standards.

4.8.3. Principle 17. Psychiatrists and psychologists, given the burden of deciding who to recommend for hormonal and surgical sex-reassignment and for whom to refuse such recommendations are subject to extreme social pressure and possible manipulation as to create an atmosphere in which charges of laxity, favoritism, sexism, financial gain, etc., may be made.

4.8.4. Principle 18. Psychiatrists and psychologists, in deciding to make the recommendation in favor of hormonal and/or surgical sex-reassignment share the moral responsibility for that decision with the physician and/or surgeon who accepts that recommendation.

4.8.5. Principle 19. A plethora of theories exist regarding the etiology of gender dysphoria and the purposes or goals of hormonal and/or surgical sex-reassignment such that the psychiatrist or psychologist making the decision to recommend such reassignment for a patient does not enjoy the comfort or security of knowing that his decision would be supported by the majority of his peers.

4.8.6. Standard 8. The psychiatrist or psychologist recommending that a patient applicant receive surgical (genital) sex-reassignment must obtain peer review, in the format of a psychiatrist or psychologist peer who will personally examine the patient applicant, on at least one occasion, and who will, in writing state that he or she concurs with the decision of the original psychiatrist or psychologist. Peer review (a second opinion) is not required for hormonal sex-reassignment nor for nongenital surgical sex-reassignment. At least one of the two behavioral scientists making the favorable recommendation for surgical sex reassignment must be a psychiatrist.

4.9.1. Standard 9. The physician administering or performing surgical (genital) sex-reassignment is guilty of professional misconduct if he or she does not receive written recommendations in favor of such procedures from at least two behavioral scientists; at least one of which is a psychiatrist and one of whom has known the patient in a professional relationship for at least 6 months.

4.10.1 Principle 20. The administration of androgens to females and of estrogens and progesterones to males may lead to mild or serious health-threatening complications.

4.10.2 Principle 21. Persons who are in poor physical health, or who have identifiable abnormalities in blood chemistry, may be at above average risk to develop complications should they receive hormonal medication.

4.10.3. Standard 10. The physician prescribing hormonal medication to a person for the purpose of effecting hormonal sex-reassignment must warn the patient of possible negative complications which may arise and that physician should also make available to the patient (or refer the patient to a facility offering) monitoring of relevant blood chemistries and routine physical examinations including, but not limited to, the measurement of SGPT in person receiving testosterone and the measurement of SGPT, Billirubin, triglycerides and fasting glucose in persons receiving estrogens.

4.11.1. Principle 22. Genital surgical sex reassignment includes the invasion of, and the alteration of, the genito- urinary tract. Undiagnosed pre-existing genito-urinary disorders may complicate later genital surgical sex reassignment.

4.11.2. Standard 11. Prior to genital surgical sex reassignment a urological examination should be conducted for the purpose of identifying and perhaps treating abnormalities of the genito-urinary tract.

4.12.1. Principle 23. The care and treatment of sex-reassignment applicants or patients often causes special problems for the professionals offering such care and treatment. These special problems include, but are not limited to, the need for the professional to cooperate with education of the public to justify his or her work, the need to document the case history perhaps more completely than is customary in general patient care, the need to respond to multiple, nonpaying, service applicants and the need to be receptive and responsive to the extra demands for services and assistance often made by sex- reassignment applicants as compared to other patient groups.

4.12.2. Principle 24. Sex reassignment applicants often have need for post-therapy (psychologic, hormonal and surgical) follow-up care for which they are unable or unwilling to pay.

4.12.3. Principle 25. Sex reassignment applicants often are in a financial status which does not permit them to pay excessive professional fees.

4.12.4. Standard 12. It is unethical for professionals to charge sex-reassignment applicants "whatever the traffic will bear" or excessive fees far beyond the normal fees charged for similar services by the professional. It is permissible to charge sex reassignment applicants for services in advance of the tendering of such services even if such an advance fee arrangement is not typical of the professional's practice. It is permissible to charge patients, in advance, for expected services such as post therapy follow up care and/or counseling. It is unethical to charge patients for services which are essentially research and which services do not directly benefit the patient.

4.13.1. Principle 26. Sex-reassignment applicants often experience social, legal and financial discrimination not known, at present, to be prohibited by federal or state law.

4.13.2. Principle 27. Sex-reassignment applicants often must conduct formal or semi-formal legal proceedings (ï.e., in-court appearances against insurance companies or in pursuit of having legal documents changed to reflect their new sexual and genderal status, etc.).

4.13.3. Principle 28. Sex-reassignment applicants, in pursuit of what are assumed to be their civil rights as citizens, are often in need of assistance (in the forms of copies of records, letters of endorsement, court testimony, etc.) from the professionals involved in their case.

4.13.4. Standard 13. It is permissible for a professional to charge only the normal fee for services needed by a patient in pursuit of his or her civil rights. Fees should not be charged for services for which, for other patient groups, such fees are not normally charged.

4.14.1. Principle 29. Hormonal and surgical sex-reassignment has been demonstrated to be a rehabilitative, or habilitative, experience for properly selected adult patients.

4.14.2. Principle 30. Hormonal and surgical sex-reassignment are procedures which must be requested by, and performed only with the agreement of, the patient having informed consent. Sex-reannouncement or sex-reassignment procedures conducted on infantile or early-childhood intersexed patients are common medical practices and are not included in or affected by the present discussion.

4.14.3. Principle 31. Sex-reassignment applicants often, in their pursuit of sex-reassignment, believe that hormonal and surgical sex-reassignment have fewer risks than such procedures are known to have.

4.14.4. Standard 14. Hormonal and surgical sex-reassignment may be conducted or administered only to persons obtaining their legal majority (as defined by state law) or to persons declared by the courts as legal adults (emancipated minors).

4.15.1. Standard 15. Hormonal and surgical sex-reassignment may be conducted or administered only after the patient applicant has received full and complete explanations, preferably in writing, in words understood by the patient applicant, of all risks inherent in the requested procedures.

4.16.1. Principle 32. Gender dysphoric sex-reassignment applicants and patients enjoy the same rights to medical privacy as does any other patient group.

4.16.2. Standard 16. The privacy of the medical record of the sex-reassignment patient shall be safeguarded according to procedures in use to safeguard the privacy of any other patient group.

5. Explication

5.1. Prior to the initiation of hormonal sex reassignment:

5.1.1. The patient must demonstrate that the sense of discomfort with the self and the urge to rid the self of the genitalia and the wish to live in the genetically opposite sex role have existed for at least 2 years.

5.1.2. The patient must be known to a licensed psychiatrist or psychologist for at least 3 months and that psychiatrist or psychologist must endorse the patient's request for hormone therapy.

5.1.3. The patient must have been successfully living in the genetically other sex role for at least 3 months.

5.1.4. Prospective patients should receive a complete physical examination which includes, but is not limited to, the measurement of SGPT in persons to receive testosterone and the measurement of SGPT, Billirubin, triglycerides and fasting glucose in persons to receive estrogens.

5.2. Prior to the initiation of non-genital surgical sex-reassignment.

5.2.1. See 5.1.1.

5.2.2. See 5.1.2.

5.2.3. The patient must have been successfully living in the genetically other sex role for at least 6 months.

5.3 Prior to the initiation of genital sex-reassignment (penectomy, orchidectomy, castration, vaginoplasty, mastectomy, hysterectomy, oophorectomy, salpingectomy, vaginectomy, phalloplasty).

5.3.1. See 5.1.1., above

5.3.2. The patient must be known to a licensed psychiatrist or psychologist for at least 6 months and that psychiatrist or psychologist must endorse the patient's request for genital surgical sex-reassignment.

5.3.3. The patient must be evaluated at least once by a licensed psychiatrist or psychologist other than the psychiatrist or psychologist specified in 5.3.2. above and that second psychiatrist or psychologist must endorse the patient's request for genital sex-reassignment. At least one of the behavioral scientists making the recommendation for genital sex-reassignment must be a psychiatrist.

5.3.4. The patient must have been successfully living in the genetically other sex role for at least one year.

5.3.5. An urological examination should be performed.

5.4. During and after services are provided

5.4.1. The patient's right to privacy should be honored.

5.4.2. The patient must be charged only appropriate fees and these fees may be levied in advance of services.

DSM III (proposed) -- Diagnostic and Statistical Manual (3rd edition, proposed) Washington, D. C. The American Psychiatric Association, 2nd printing 1/15/78.

Report prepared February 12, 1979

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