Dallas Denny on the Standards of Care
Some Notes on Access to Medical Treatment: A Position Paper
by Dallas Denny, M.A.
Licensed Psychological Examiner
Executive Director, American Educational Gender Information Service, Inc.

Access to hormonal therapy and plastic surgery (including SRS) is a critical need for transgendered
and transsexual persons. Access has been limited since 1979 by the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc., an organization composed of physicians and mental health professionals. The Standards were formulated in order to provide guidelines for access to medical treatments, which had to that point been unregulated. The Standards of Care (SOC) are minimal guidelines, and are updated regularly (most recently in 1991; they are currently being revised once again).

To put in a nutshell the constraints which the SOC place on treatment: they require a period of 90
days of therapy before beginning hormones, and a one year real-life test before sex reassignment
surgery. They also specify what is and is not professional behavior about care of transsexual people. However, the SOC are not law, are not required of any mental or physical health professional. Nonetheless, they are widely followed, and a professional who does not follow them can receive professional censure.

At the time of their formulation, treatment of transsexual people was unregulated, and there was a
great deal of (to borrow a term from Geraldo) "transsexual regrets;" this happened most frequently
when the individual had genital surgery with little or no preparation for life in the new gender.

Clinicians, beginning with Harry Benjamin, had found that the real-life test (living and working or
going to school full-time) was an excellent predictor of good post-operative adjustment. The Gender Identity Clinic at Johns Hopkins University used a real-life test, as well.

In 1979, sex reassignment was even more controversial than it is today. The group which founded
HBIGDA (and formulated the SOC) was the group of professionals who believed that sex
reassignment was a viable treatment for transsexual people ( as opposed to another group, largely
comprised of psychiatrists, who believed that it was not). The Standards of Care, by their general
acceptance as professional standards, lessened the chance of sex reassignment, and especially SRS
being declared illegal and protected those who provided medical procedures from being censured
by their peers ("But look, see, these are actual Standards of Care.") They also lessened the chance
of being sued by disgruntled former patients (calls to mind the term "Disgruntled Postal employee,
doesn't it? Well, one surgeon was shot to death by a transsexual patient).

Because the SOC were minimal standards, they frequently were (and sometimes still are) zealously
overinterpreted. Access to hormones and surgery were oft-promised and seldom delivered, and
were, in fact, frequently used like carrots at the end of stick. Some transsexuals were kept in
abeyance for years with false promises. Others were required (read forced) to make changes in their sexual orientation, marital status, career, manner of presentation, name, and physical characteristics. Many were required to live full time for extended periods before hormonal therapy.

Unfortunately, this sort of abuse still continues. In a recent article in Archives of Sexual Behavior,
two members of the gender identity clinic at the Clarke Institute of Psychiatry surveyed a variety of
gender programs, and found all of these things still occurring at some clinics.

While most therapists, endocrinologists, and plastic surgeons don't have a clue about transsexual and transgendered persons, many others do. Some are "old school," and act as if transsexualism were some dread disease which they might catch, and which might go away if they can put enough
obstacles in the transsexual person's path. Others (many of whom are transsexual themselves) are
"new school," and don't necessarily think that transsexualism is a pathology. Therapy is seen as a
means of allowing the transsexual person to become aware of his or her options (many aren't
aware), and to help to work through difficulties which can arise in the coming out process and during transition.

There have been very vocal criticisms of the SOC; ICTLEP, the International Conference on
Transgender Law & Employment Policy, has adopted Health Care Standards (which were
formulated without input from medical professionals), which declare any provider of medical services who does not provide that service to all transsexual and transgendered people who give informed consent (absent a medical condition which would negatively affect health). These Standards have been distributed, (they were even distributed at the 1993 HBIGDA conference in New York City), but passed largely without comment. In our opinion, these Health Care Standards of Care make an excellent Bill of Rights for Transsexual and Transgendered persons, but lack credibility as Standards of Care

In 1993, AEGIS did a survey of the HBIGDA SOC. We included forms in a mailing of Chrysalis,
our magazine, and sent them to a variety of support groups. We received over 300 replies. We have analyzed the data and presented them at the Spring 1994 Eastern Regional meeting of the Society for the Scientific Study of Sexology in Atlanta and at the First International Congress on Gender, Crossdressing, and Sex Issues in Van Nuys, CA. The report on our findings will be published in a book edited by Vern Bullough, RN, Ph.D., and published by Prometheus Press.

Those who wish a copy of the report can receive one by sending $2.00 to AEGIS, P.O. Box,
33724.

One of the most interesting findings was that more than 90% of respondents (who were largely
transsexual) believe that there should be some regulation of access to hormonal therapy and genital
surgery.

This is not surprising, since access to such techniques as prescription medicine and surgery are
limited. Medication is available only with a prescription from a physician, by way of a pharmacist,
and surgery is available only from a physician.

These are important findings, for it means that the loud voices we hear dissing the SOC come from
less than 10% of the sample population, which we believe is fairly representative of the population of transsexual and transgendered people in the transgender community.

On the other hand, the respondents acknowledged that the SOC were far from perfect and did not
take into account the individuality of transsexual people.

This is not surprising either, since regulations on access to treatment for transsexual people go far
beyond those for any other group of people, and are frequently quite repressive.

We at AEGIS believe that the issue of access to hormonal therapy and surgery is in need of
renegotiation. However, we also believe that free access would result in lives ruined and lives lost
and in a great deal of human misery-- not for everyone, to be sure, but for a significant percentage of the transgender community.

We absolutely believe that being transgendered or transsexual is not a disorder, not a mental illness,
not a birth defect; it is, rather, a special way of being which has occurred in all cultures throughout
history. However, we also acknowledge that many transsexual and transgendered persons have
serious mental health and substance abuse issues, that many have histories of physical and sexual
abuse as children, and that many have been rendered dysfunctional because of societal reactions to
their transsexual or transgendered nature. Many operate from deep within shame and denial.
Furthermore, general societal lack of information and misinformation about transsexualism, coupled
with the turmoil experienced when coming to terms with one's gender issue, can leave many of us
temporarily or permanently far from our best when making important decisions about our lives. Also, many who seek sex reassignment change their minds, and for various reasons-- sometimes because of external difficulties, and sometimes because of shame and guilt and denial-- drop their plans to change their gender. Others, upon learning of newly emerging options (e.g. transgenderism) change their plans (i.e., decide that surgery is unimportant to them).

While some of us have suffered abuse at the hands of mental health professionals, others have been
empowered. As more and more professionals come on line absence the prejudices of early
therapists, the frequency and severity of this abuse can be expected to decrease.

We find a ninety-day holding period before initiation of hormonal therapy to be advisable, and a one year period of RLT before genital surgery. However, as we said, renegotiation is in order. Certainly, clearly defined criteria (both minimum and maximum) for access to hormones and surgery should be made clear to the transsexual or transgendered individual (In other words, You get it unless... vs. You get it if...) Only when there are clear contraindicating mental or physical issues (i.e., severe psychosis, severe phlebitis) should treatment be denied.

The issue of access to medical treatment is not a closed one. It is currently being renegotiated, and
will likely be for some time to come. There are many things to consider: What, for instance, is wrong with a nontranssexual individual who wants a vagina, but wishes to live as a man? Why should he be denied surgical treatment? What about those whose golden parachute makes it financial suicide to come out at work, but who otherwise live full-time? And what function should mental health professionals play in access to medical treatment? (i.e., Why should they be the heavies? Isn't that the physician's' job?)

This renegotiation will be best conducted with mutual respect between transgendered and
transsexual people and mental and physical health professionals. Angry rantings against mental health professionals, as has occurred all too frequently on this USENET group, serve only to vent the spleen of the poster, and may lead people who are in need of psychological care to not get it.

We are convinced, after fielding thousands of calls over a period of five years, that free access to
medical treatment would be disastrous. We are equally convinced that there should be a clear,
non-obstructionistic process to get access to these treatments, and that transsexual people should
not be singled out for special restrictions that are not given to other, less marginalized groups.