In many countries or areas, an individual's pursuit of sexual reassignment surgery (SRS) is often governed, or at least guided, by documents called standards of care (SOC), or standards of care for gender identity disorders. Various medical and psychiatric fields have developed similar protocols for treatments, covering topics ranging from diabetes patients to sexual abuse victims.
Prior to the advent of the first SOCs, there was no semblance of a consensus agreement on psychiatric, psychological, medical, and surgical management of gender identity disorders. Before the 1960s, few countries offered safe, legal medical options and many criminalized cross-gender behaviors or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment." These standards are still the most well known, however, other sets of SOCs, protocols and guidelines do exist, especially outside the USA.
The Standards of Care for Gender Identity Disorders by the Harry Benjamin International Gender Dysphoria Association
These Standards of Care (HBIGDA-SOC) are the most widespread SOC used by professionals working with transgendered persons. The HBIGDA-SOC are periodically updated and revised as new scientific information becomes available. The latest revision was released February 20, 2001. This is the sixth version of the HBIGDA-SOC since the original 1979 document was drafted. Previous revisions were released in 1980, 1981, 1990, and 1998. The HBIGDA 18th Biennial Symposium will be held September 10-13, 2003, in Ghent, Belgium, which could mean that yet another revision of the SOC might be available in the near future, considering the rapidly changing field of treatment options as well as patient demands.
Included in the guidelines are sections on epidemiology, mental health professionals, treatment of children, adolescents and adults, hormone replacement therapy, the Real-Life Experience (RLE), which was formerly called the Real-Life Test, and, of course, surgery.
HBIGDA-SOC sections Ten through Twelve (of thirteen) specifically cover the surgical treatment of transsexuals. Section Twelve, titled "Genital Surgery," deals directly with all concerns about sexual reassignment surgery. It includes six "Eligibility Criteria" and two "Readiness Criteria", which are intended to be used by professionals for both diagnosis and guidance before providing patients "letters of recommendation."
The current revision mandates that mental health professionals document a patient's relevant history in a letter which should be required by medical professionals prior to physical intervention. One letter is required for hormone replacement therapy or either augmentation mammoplasty or mastectomy. Two additional letters are needed for genital surgeries.
The Eligibility Criteria and Readiness Criteria give certain very specific "minimum" requirements as prerequisites to HRT or SRS. For this and many other reasons, the HBIGDA-SOC is a highly controversial and often maligned document among transsexual patients seeking surgery, many of whom claim that their legally protected right to proper medical care and treatment is unjustly and unduly withheld or even denied based on the SOC. This frequent disdain is in spite of and quite possibly the cause of increasingly less stringent professional adherence to the SOC, as well as a general reduction or deletion of some pre-surgical mandates in recent revisions of the HBIGDA-SOC. The majority of qualified surgeons North America and many in Europe adhere almost unswervingly to the HBIGDA-SOC.
Treatment according to such older SOCs is often reserved for transsexuals only, not for other transgendered people who for example might not want to undergo the complete set of treatments, or who see themselves outside a binary gender system.
In Western countries the emphasis is on psychiatry or psychology, typically in Latin America the emphasis is on the ability to "pass" and in Thailand the emphasis is on cross-living experience.
Other SOCs, protocols and guidelines for the treatment of gender identity disorders
In some countries or areas, local standards of care exist, such as in the Netherlands, Germany or Italy. Also, some health care providers have their own set of SOCs which have to followed to have access to health care.
The criticism about the HBIGDA-SOCs applies to these as well; some of these SOCs are based on much older versions of the HBIGDA-SOCs, or are entirely independent of them. In all of those cases, the criteria are stricter than those in the latest revision of the HBIGDA-SOCs. Treatment outside HBIGDA-SOCs.
In other regions, most notably Thailand, there are doctors who follow alternative standards and who will actually arrange surgery dates over the Internet and operate on any person who meets financial and other criteria. Some of these surgeons charge as little as one fourth of the fees demanded by the average Western surgeon, and as little as one tenth of the cost of some well-known and highly respected surgeons in the US. A dramatic elevation in surgical and post-surgical risks as well as an increased possibility of post-surgical dissatisfaction is often the exchange for lower costs and fewer pre-surgical requirements such as weight limits. In other regions, notably Latin America, surgeons follow no particular set standards and decide their own criteria for eligibility for surgery. Links
HBIGDA Standards of Care for Gender Identity Disorders
