I write this having just finished an abortive meeting with an endocrinologist to discuss a hormone regimen.

There are a number of reasons why this was a frustrating experience for us both, and I am writing in equal parts to act as catharsis for my side of the experience and perhaps to highlight some of the difficulties physicians face.

Put briefly, the endocrinologist refused to prescribe hormones because I did not meet the Benjamin standards of care. The fact that this was not mentioned prior to my referral was frustrating to say the least, and the fact that it was not mentioned until the final 5 minutes of our consultation suggests poor time management on the physician’s part.

These standards were established with good intentions in mind:

To provide an ethical safety net for those in the health care profession who deal with transgendered and transsexual people.

To act as protection against making substantial (and largely irreversible) decisions without benefit of counseling

The challenge arises from two key areas:

1. The stringency of the Benjamin Standard
2. The vast differences in expected outcomes and transgender experiences

The Benjamin Standard is not static. Rather it is modified periodically to reflect changes in our understanding of gender. The details therefore, (such as living 12 months in the gender of assignment, receiving counseling etc.) are less important than the ultimate diagnosis that the standard is supposed to identify.

Namely: It identifies gender dysphoria that is so severe and chronic in nature that it will only respond to aggressive medical intervention.

Expressed in plain language, the standard establishes that you must be so distressed by existing in your birth gender that (if something isn’t done about it) you will injure yourself.

It should therefore come, as no surprise that what little data exist on the outcomes of pre and post-operative transsexuals is depressingly consistent.

That there is an outrageously high incidence of suicide or death from other violent means is entirely consistent with a standard that only allows treatment for those who have done such things as attempt to castrate themselves or to perform self-mastectomies.

Even in the absence of such dramatic attempts at auto-surgery. The core concept of the standard is flawed.

Severe gender dysphoria can be defined as a gender biased form of self-hatred.

To my knowledge, self-hatred as a pre-qualification for medical intervention is not a pre-requisite for a nose job. Neither should it be a pre-requisite for hormone therapy nor other modest forms of intervention.

The irony of this standard is that it serves to ensure that only those people who are the least well adjusted to their body image and sense of self are those who are eligible to receive care.

By analogy, it is like saying that cancer will only be treated after a 12-month period to confirm that it has truly metastasized.

This leads to another systemic irony. The standard is biased towards the most extreme examples of intervention. In other words, that the standard is based on the assumption that the ultimate goal is transition via sexual re-assignment surgery.

While this may be the proper course for some bi-gendered people, I do not believe it is right for all people.

As laudable as the original intentions might have been, the net effect is that the only way to legally obtain hormone therapy or other low levels of transgender care is to endure a dehumanizing and de-constructive process.

Gender expression is neither as frivolous as a nose job, nor as pervasive as cancer, but it is serious in its own right. Left untreated (as the Benjamin standards demand) it causes outcomes that are as predictable as they are tragic.

If one leans towards "gallows" humor the following illustrates a point.

Q. How can one accurately diagnose a transgendered person?

A. At the coroner’s inquest…it’s usually in the suicide note.

To wait until someone’s cancer has metastasized before attempting to operate or treat it would be considered inhumane. To wait until someone attempts to cut off their own nose before ethically allowing intervention would be considered a mediaeval approach to diagnosis and care.

Yet that is precisely what the well-intentioned Benjamin standards achieve. It serves as a bludgeon beating the transgendered person into a course of action and behavior that is inherently destructive.

For my part, I am now faced with several courses of action, none of which is appealing. I am committed to modifying my body so that it more properly expresses what I feel inside. I utterly refuse to accept the proposition that this is an irrational or imbalanced point of view. Yet, paradoxically, in order to receive credible prescriptions and treatment I have to pretend that I am prepared to mutilate my birth genitalia in order to receive that treatment.

It is an understatement that the patient is not best served by this approach, but then, neither is the physician. The endocrinologist that I saw was also frustrated by the trials and tribulations associated with the care of the transgendered.

Although it is not strictly speaking a definition, severe gender dysphorics who meet the exacting standards of care are extremely likely to have other dysphoria and emotional/psychological issues.

This then sets up the physician’s ethical catch-22: The majority of patients that they get to see are those who are emotionally distressed and therefore inappropriate candidates.

The sane ones aren't crazy enough to be eligible! 

(Editors note: January - March 2001
Bad as the standards are, they are the best we have. They have recently changed (In part because of the issues discussed above). At the very least, please ensure that your physician is using the current version !
THE STANDARDS OF CARE FOR GENDER IDENTITY DISORDERS -- SIXTH VERSION. Click here)