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STANDARDS OF CARE FOR
HARRY BENJAMIN'S SYNDROME
I.
Introduction
II.
Purpose
III.
Scope
IV.
Principles
VI.
Epidemiological
Considerations
VIII.
Classification
and Terminology
IX.
Requirements
for Professionals
XI.
Treatment
of HBS in Children
XII.
Treatment
of HBS in Adolescents
XIII.
Treatment
of HBS in Adults
XIV.
HBS
along with other conditions
XV. Genital, Breast, and Other Surgery for the Female Patient XVI. Breast and Genital Surgery for the Male Patient XVII. HBS along with other conditions.
XVIII.
Artificially
Induced HBS
I.
INTRODUCTION
Harry Benjamin’s Syndrome (HBS) is named in honor of the man
who recognized the condition as a medical anomaly and advanced its treatment,
Dr. Harry Benjamin. It was through his compassionate understanding and abiding
interest that he came to recognize and define the condition. Over the course of his career, with
dedication and vision, he developed and refined treatment methods to help
people affected by what we now know as HBS.
It should be clearly understood that Harry Benjamin’s
Syndrome is not a choice, any more
than Turner’s Syndrome or Lou Gehrig’s Disease (ALS) is a choice. Nor is it a result of nurture (i.e. artificially
developed through parenting and environment). HBS is an inborn biological anomaly, a natural occurrence, as are all
intersex conditions.
The purpose of the Standards of Care for Harry Benjamin’s
Syndrome (SOC-HBS) is to codify HBS and establish a new paradigm for the
effective management of patients afflicted with Harry Benjamin’s Syndrome
(HBS).
The Standards of Care for Harry Benjamin’s Syndrome
(SOC-HBS) are intended to serve
·
as an educational aid - to present a clear understanding
of HBS to the global community at large.
·
as a reference source - to offer coherent medical
treatment guidelines for health care professionals.
·
as a motivating source for change - to factually challenge current
treatment methods and suggest improvements.
·
as a summons - to petition the scientific community
to refresh and broaden research efforts and to advance essential perspective.
Professionals are encouraged to utilize this document to
enhance their understanding of HBS and develop appropriate and effective
treatment strategies for their patients.
Persons born with HBS, their families, social
institutions, and legal bodies may use the SOC-HBS to gain a comprehensive understanding
of HBS and an awareness of the principles by which it is currently understood.
IV.
PRINCIPLES
HBS is a biological variation in human sexual formation
where the sex indicated by the phenotype and the genotype is opposite the
morphological sex of the brain.
Principle 2: Persons born with Harry Benjamin’s Syndrome
seek rehabilitation of their phenotype and endocrinology to accord with
their sex.
Persons born with HBS have both male and female
characteristics. Sex (i.e. gender identity
or awareness of sex) is irreversibly determined
by the structure of the brain. Sex
organs (genitals) are determined genetically through chromosome selection
during conception and gestation. Harry
Benjamin’s Syndrome is the untenable situation arising from the contradiction
of having mismatched brain sex and sex organs (genitals). HBS, then, is concerned with altering one’s
physical sex to match one’s brain sex; it is about recognizing and respecting gender
norms.
Principle 3: Harry Benjamin’s Syndrome is an ancient and
persistent form of human nature, not a modern discovery.
Historical narratives show that Harry Benjamin’s Syndrome
has existed throughout history; HBS is not new to this century. It should be recognized as a natural phenomenon,
another form of the human condition. It
is separate and distinct from sexuality. Most adamantly it must not be confused with displays of modern day
gender-variant expressions.
Principle 4: Persons born with Harry Benjamin’s Syndrome
have the right to obtain adequate medical care for their condition as soon
as they request it, without discrimination.
Harry Benjamin’s Syndrome is a legitimate medical
condition and it should be given the same consideration
and respect and rigorous approach as any other medical condition. All public and private health systems should
respond to requests for assistance to the best of their ability and with all
due dignity and respect to the person making the request, without
discrimination.
Principle 5: Persons with Harry Benjamin’s Syndrome have
the right to preserve their identity, intimacy, and privacy regarding all
aspects of their condition and situation.
Labels, apart from ‘male’ or ‘female’, are unacceptable
and dehumanizing. The application and
use of labels such as ‘pre-op transsexual’ dishonors HBS sufferers and serves
no purpose other than as expressions of ignorance. Medical care and treatment should be soberly and professionally
conducted, without adding stigma.
Principle 6: Harry Benjamin’s Syndrome is an innate,
life-threatening condition; its treatment is essential for survival.
Due to common misperceptions there is a social stigma that
surrounds HBS. Fed and sustained by
ignorance, HBS causes societal and family discrimination, pressure, and stress.
Many of those suffering from this syndrome have been forced to accept ridicule
and denial from family, friends, co-workers, and other segments of society,
which understandably exerts a deep dysphoria. Social withdrawal, depression and suicide (attempted or actualized) are
not uncommon reactions to the trauma induced by such conditions.
Following Sex Affirmation Surgery suicide rates
among HBS patients fall to the societal average, and depression typically resolves
by degrees until normalcy returns. This
in itself is an indication of the profound restorative effects of HBS treatment
protocols.
Principle 7: Harry Benjamin’s
Syndrome patients have the right to function in society with full dignity
and respect, including functional legal rights, regardless of their
incongruous, albeit temporary, physical circumstances during corrective
treatments.
Widely disparate local, regional, national, and
international laws constrict the rights and legal status of HBS patients. It is suggested that jurisprudence and the
various legal systems be reviewed and updated to confer legal status for HBS
persons experiencing the 'Real Life Test' phase of their affirmation
process, and while on hormone preparation be allowed to change functional documentation
that would allow them to work and function in their true sex.
This documentation should be provided with a
term limit suggested to coincide with the actual 'Real Life Test’ period. Such temporarily amended documentation
should only be provided by the appropriate agencies after the request is
authenticated with a physician’s diagnosis confirming Harry Benjamin’s Syndrome.
Unless one has had Sex Affirmation Surgery (SAS), birth
certificates should be neither permanently changed nor temporarily amended.
That would be a contradiction of facts and lead to societal and legal
confusion. Birth certificates should reflect the actual physical sex of an
individual, not the attitude or presentation of a personality.
V.
DEFINITION AND ETIOLOGY
We now know that the brain is the organ that defines sex;
that is, sex is determined by brain structure, not by genitalia. Therefore girls
born with Harry Benjamin's Syndrome have a female brain sex but her
genitals are male. Boys born with this condition have female genitalia
even though their brain sex is male.
The difference between Harry Benjamin’s Syndrome
and most other intersex conditions is that there is no apparent pre-birth evidence
nor, to date, are there any absolute, definitive diagnostic procedures. Diagnosis of HBS is thus delayed until its effects become
symptomatic. Sadly,
this results in raising babies in the wrong gender role.
VI.
EPIDEMIOLOGICAL CONSIDERATIONS
Research studies have shown anywhere from 1 out of
500 births to 1 out of 30,000 births are born with Harry Benjamin’s Syndrome. In view of such widely variable statistics,
it must be acknowledged that factual numbers remain elusive. Until such time as a controlled study can
authoritatively be undertaken, preferably on a global scale using factually
formulated criteria, such data remains uncorroborated.
Verifiable (i.e. repeatable and reproducible)
epidemiological research is encouraged in order to establish a statistical
foundation from which to advance further research.
Regardless of the lack of verifiable statistical ratios it
can certainly be agreed upon that HBS, as a rare intersex anomaly, affects only
an exceedingly small portion of the population.
Harry Benjamin's Syndrome was known in the past under
many different names, transsexualism being the most common. However, Harry Benjamin's Syndrome is not transsexualism, at least not
under the current definition of transsexualism provided by the ICD-10
which considers it a mental condition with a psychological cause.
As has been shown, Harry Benjamin’s Syndrome is a physical
condition indicative of a fetal anomaly and to continue to categorize it
as a mental condition is outdated and unfair; it wrongly denies patients with
Harry Benjamin’s Syndrome essential medical care by placing them under
inappropriate standards of care. -HBS in Adults
VIII.
CLASSIFICATION AND TERMINOLOGY
Harry Benjamin's Syndrome is named after Dr. Harry Benjamin,
a visionary physician and pioneer researcher who contributed significantly to
the recognition, understanding, and treatment of HBS, which he knew in his time
as transsexualism. His medical
biography stands alone in contemporary medical history as the most significant,
most respected, and most authoritative relative to this syndrome. (See also his published work The Transsexual Phenomenon, Benjamin, 1966.)
Harry Benjamin's Syndrome and its acronym HBS are the
preferred replacements for current terminologies because they lend historical
substance and a coherent medical essence to the condition, whereas other
terminologies instill distortion or possess misleading connotations.
·
Previously
defined
·
Individualized
program of hormone treatment based on the assessed endocrinological needs of
each patient. HRT mimics, or
‘replaces’, the otherwise missing hormone-producing glands or organs of the
affirmed sex.
·
The
primary surgical removal/alteration/reconstruction of genitals/sex organs to
match those of the affirmed sex.
Affirmation, Affirmation process
·
Formerly
referred to as ‘transition’, affirmation is the realization process wherein the
HBS patient moves from living their assumed (extrinsic) gender role to living their
affirmed (intrinsic) gender role.
Intersex, Intersexed, Intersexual (IS)
·
Having
characteristics of both male and female including, in varying degrees, reproductive
organs, secondary sexual characteristics, and/or sexual behavior resulting from
a sex chromosome abnormality or a hormonal imbalance during embryogenesis.
Reflections about
other terminologies commonly used in the past:
·
Transsexual
The contemporary term for Harry Benjamin's Syndrome is transsexualism,
coined by sexologist Magnus Hirschfeld in the 1920's. The term transsexual is a combination of two words: trans + sexual. The word trans is a Latin prefix which means across, beyond, through. The word sexual is an adjective derived from the Latin sexualis which means relating to, or associated with, sex or the sexes.
The term transsexual was originally conceived as a means to confer a biological cause for
homosexuality and other anomalous sexual behavior. It soon became synonymous with those who ‘change sex’. It seemed suitable. Unfortunately, the term’s original meaning has since been
eclipsed and co-opted by the media as well as non-transsexual persons, creating
inextricable confusion. Its continued
use in today’s world has been rendered untenable for those who could otherwise
legitimately claim its usage.
The term transsexual commonly
evokes a connection to sexual orientation that does not exist. Sex and sexual orientation are unrelated characteristics. Thus, inclusion of the word ‘sex’
presupposes undesired connotations.
The term bears enough of a superficial similarity to transvestism and transgenderism so that it is easily confused. This inappropriate correlation of completely
unrelated phenomenon serves to further corrupt the term’s original intent.
Worst of all, the term transsexual is commonly used as a
label which, in itself, is dehumanizing and insulting. Referring to someone as a transsexual rather
than a man or a woman makes it easier to think of them as being ‘other than’ or
‘less than’. People with Harry Benjamin's
Syndrome are people who happen to have a particular medical problem; it is a
birth defect, not an identity.
Used as an adjective, as in ‘transsexual man’ or ‘transsexual woman’, the term is no better. Rather
than clarifying the nouns ‘man’ and ‘woman’, the adjective transsexual only serves to obfuscate them. Is it any wonder, then, why most people are
confused about whether the appropriate noun for any particular individual is
‘man’ or ‘woman’? As a final note, it must be understood that HBS survivors who
have completed the affirmation process have endured
unimaginable adversity for the chance to live normal, uncompromising lives -
the type of life everyone else takes for granted. The term transsexual becomes inappropriate after the physical transformation
has been completed, for then it is no longer a question of ‘being between’ or ‘crossing
between’ the sexes as the term transsexual implies. They are whole in mind and body, and there is no further need
to refer to them for the purpose of identification as anything other than a
‘woman’ or ‘man’.
·
Transsexualism,
Transsexuality
Nor do people with Harry Benjamin's Syndrome change sex - they
don't become the opposite sex - they
already are a determinate sex, as is
everyone. Sex is not genitals or reproductive organs, sex is distinctly imprinted in the brain; it comes ‘built in’. It
cannot be reinforced enough: once biologically hard-hardwired into the brain
during gestation and birth, sex cannot
be changed.
As has been shown HBS is a biologically induced
manifestation and therefore a natural phenomenon. It is observable elsewhere in the animal kingdom, not just in
humans.
Corroborative research findings have further confirmed the
existence of biological markers for Harry Benjamin’s Syndrome. These findings, in parallel with updated
terminology, are very important historical developments. Such advancements are proving very liberating
and encouraging to those now living with the syndrome.
·
Gender
Identity Disorder
While it may be obvious that there are associated psychological symptoms resulting from the pressures of
living an inauthentic existence and the myriad social problems thus created, they must not be mistaken for the condition
itself.
While psychiatric evaluation is an essential diagnostic aid,
it should not be seen as the main focus for remediation of, or ‘curing’, HBS. Attempts to alter brain sex (i.e. one’s gender
identity) to match their bodies have been spectacularly unsuccessful. The only proven and reliably effective
treatment for HBS is to fix the body.
Falsely implying that people with Harry Benjamin's
Syndrome are mentally ill or deluded is not only inappropriate when viewed
in the light of the current state of knowledge, it is incompetent. Harry Benjamin’s Syndrome can no longer be
acknowledged or treated as a mental disorder. To continue this practice is to foster ignorance and prolong suffering.
·
Transgender
Perhaps because of its laundered verbiage (i.e. removal
of the word ‘sexual’) the term transgender has been co-opted by the lay public,
the media, and even professional care givers themselves as the politically correct term to use when referring to or describing
various forms of queer, gender nonspecific, or gender deviant personalities,
behaviors, or the persons themselves. Likewise,
the term has been adopted by the queer community (i.e. gay, lesbian, bisexual)
as a cleaner, non-threatening umbrella term that includes all forms of deviant gender
expression. Few who use the term can
offer a clear, precise definition of what transgender means, so it continues to
perplex even those who use it.
Alone, this single term has caused the greatest harm towards
understanding HBS simply by inveigling its confusing, nonspecific, user-defined
connotation into the public’s consciousness. The cumulative effect of its now popular usage has literally stifled any
attempt to redirect or reestablish the legitimacy of HBS as a true
syndrome. The term transgender is anathema to HBS and its use should be avoided at all
costs. Preference for SAS
(Sex Affirmation Surgery) above other surgical terms:
The term Sex Affirmation Surgery (SAS) is preferable to the currently
popular alternative terms Sex Reassignment
Surgery (SRS) or Gender/Genital
Reassignment Surgery for describing the operation used to help correct the
anatomies of people with Harry Benjamin's Syndrome.
There is certainly no reassignment of sex or gender since the brain sex (gender) of the person born with HBS has already been immutably established in the womb and is already as it should be. Sex Affirmation Surgery therefore speaks about the process of affirmation, i.e. correction of a physical defect, not about reassignment of sex or gender.
IX.
REQUIREMENTS FOR PROFESSIONALS
1.
Doctorate
degree of Medicine (MD).
2.
Master’s
degree, or its equivalent, in a clinical behavioral science field.
3.
Specialized
training in the assessment, management and treatment of Harry Benjamin’s
Syndrome.
4.
Continuing
education in the discipline of Harry Benjamin’s Syndrome, which may
include attendance at professional meetings, workshops, seminars, or participation
in areas of research related to Harry Benjamin’s Syndrome.
The medical community of today is perfectly capable of
successfully treating Harry
Benjamin's Syndrome but still lacks effective diagnostic
tools. This failure can be traced to a lack
of information and research data about this condition, therefore leaving
doctors with outdated treatment options mired in the myths of the past.
Once diagnosed, treatment options are often greatly
complicated by the negative intervention of health insurers. Historically, the health care insurance
industry has done substantial harm to HBS sufferers by denying or obstructing
required and necessary treatment.
We are beginning to
see the winds of change regarding global recognition of HBS and its need for
medical inclusion within the health care community. Research, though painfully slow, is gaining ground in forging awareness
and concern towards a more comprehensive and compassionate understanding of HBS. Slowly, inroads to viable treatment options
are being laid around the world as countries are coming to grips with the
reality of HBS and the recognition that it can, and must, be effectively
managed – to the benefit of all.
Diagnosis
Harry Benjamin’s Syndrome is distinctive in that
it is a self-diagnosed condition; that is, people with HBS are exclusively aware
of its presence and the onus for articulating its existence lies with them.
Regrettably, most HBS patients are aware of it
from early childhood, long before they are old enough to articulate its essence. As a result, they invariably suffer an
existence of prolonged isolation and confusion. Ironically, once capable of understanding the nature of their
dilemma, they are almost universally stigmatized into keeping it secret until
such time as they can no longer tolerate suffering its destructive
effects.
It is at this point of discovery and disclosure
that every effort must be made to confirm the HBS patient’s
self-diagnosis. Currently there is no diagnostic
test or procedure that can unequivocally prove a patient’s contention that
their brain sex is opposite from their genital sex. There are, however, systematic methods for validating and
confirming the syndrome’s existence.
Once a patient seeks help, diagnosis must be competently approached
through objective medical and psychological/psychiatric examination to rule out
other possibilities, of which there are many. Upon confirmation, medical treatment must be immediately offered, and
without undue delay.
In most cases, it is difficult to give a diagnosis
before late infancy or pre-adolescence, although countries like the Netherlands
are very advanced in diagnosing and treating this syndrome. Thanks to the hard
work of Cohen-Kettenis, people living in the Netherlands are able to start the
treatment before puberty.
Treatment
The alignment of the HBS patient’s body to their brain sex
is a complex process that is not easily undertaken, nor instantly
gratifying. Though HBS patients
unhesitatingly welcome the severity of the challenge, it may best be approached
through realistic goal setting. Regardless of expectations, successful treatment requires time, resources,
and commitment. Treatment will include:
ü
Hormone Replacement Therapy (HRT)
ü
Sex Affirmation Surgery (SAS)
ü
Therapeutic Counseling, if
required
Hormone Replacement Therapy (HRT):
In order to prepare the body for SAS, hormone treatments are
typically the first step. It is
advisable to visit an endocrinologist, preferably one skilled in the treatment
of HBS and who has up-to-date information regarding such treatment.
Genotype and HY antigen testing, if optionally undertaken,
may reveal matching genotype and phenotype, as well as HY antigen response, for
the affirming sex (brain sex) but are neither predictable nor conclusive
indicators.
As an example, many girls with Harry Benjamin’s
Syndrome already have clearly feminine physical forms and bone structure prior
to starting HRT, but such physical characteristics are secondary in nature and
should not be assessed as primary diagnostic indicators.
These secondary sex characteristics (physical
features) appear in only a minority of HBS patients. While inconclusive on the whole, their occurrence does add to the
evidence that HBS is a physical, rather than a mental, condition.
Sex Affirmation Surgery (SAS):
Sex Affirmation Surgery is the surgical process
of altering one’s genital sex to match their brain sex. In successfully completing this process the
HBS patient is ‘affirming’ their sex; that is, they have affirmatively taken
charge of their lives to surgically correct their genital anomalies.
Therapeutic counseling (re-establishing psychological
comfort):
Early treatment of Harry Benjamin's Syndrome can have a
profound, deeply restorative effect. However,
there is no ‘magic bullet’ treatment that can guarantee immediate or prolonged
relief from the cumulative effects of living with the syndrome.
Each HBS patient is certain to experience some degree of
psychological ill-effects from having endured years of living in the wrong sex
role, even if outward appearances hint to the contrary. It should be kept in mind by diagnosticians
and patients alike that a period of psychological readjustment following onset
of treatment is considered normal and should not be unexpected.
The adjustment period varies widely, depending on the degree
and extent of effects and the patient’s ability to process them. In some cases counseling is not required; medical treatment alone
reinstates the patient to wholeness by eliminating the cause of psychological distress
and imbalance. There are no established
‘normal’ parameters.
It cannot be stressed too strongly that, other than for initial
diagnostic purposes, long-term
psychological or psychiatric follow up is strongly contraindicated for
patients with HBS unless there are
other indications for such follow-up.
To whatever degree psychological scarring is or is not
present, it must be clearly understood that such indications are an artifact of
living with HBS, not its cause. It is essential to remember that Harry
Benjamin’s Syndrome is a biological anomaly, not a mental disorder!
XI.
Treatment of HBS in Children.
Treatment of Harry Benjamin’s Syndrome in children is a
complicated task requiring the careful diagnostic assessments of a
child-specialist mental health professional. During the diagnostic period the
individual child's gender identity and gender role behaviors, family dynamics,
past traumatic experiences, and general psychological health are separately
assessed.
Following a confirming diagnosis, a pediatric
endocrinologist can start Hormone Replacement Therapy in the child patient. HRT should only be administered in cases
where persistent and consistent feelings of body incongruity in the child
have been established and confirmed for longer than 6 months.
Sex Affirmation Surgery (SAS) can then be considered as an option to correct
the physical problem. However, the
child HBS patient should wait until they reach onset of puberty to apply for
SAS.
Given the lack of corroborative biological testing for
HBS, utmost caution must be employed
before allowing early surgeries. The surgical procedure itself is better
undertaken after the body and genitals have reached adolescence.
XII.
Treatment of HBS in Adolescents.
To minimize the risk of error, HRT should be withheld for 6
months from the initial date of diagnosis, during which time the patient’s
progress should be assessed in greater depth. Sex Affirmation Surgery can, and should, be considered after one year from
the initial HBS diagnosis.
To qualify for this treatment the adolescent patient should
meet the following criteria:
(1)
Throughout
childhood they have demonstrated an intense pattern of an incongruous nature
towards their body’s sexual identity, resulting in an aversion to expected
gender role behaviors.
(2)
Sexual
identity discomfort has significantly increased with the onset of puberty.
(3)
The
family consents to, and participates in, corrective therapy.
Hormonal treatment should be conducted in two phases. In the
initial phase females should be provided an antiandrogen (which neutralize
testosterone effects only) or an LHRH agonist (which stops the production of
testosterone only), and males 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, females may be given estrogenic agents and males
may be given higher masculinizing doses of androgens.
Medications used in the second phase (estrogenic agents for
females, high dose androgens for males) produce irreversible changes. Consequently, this must be considered as a
critical evaluation and treatment parameter.
XIII.
Treatment of HBS in Adults.
After diagnosis of HBS, HRT can be immediately started.
Psychological follow up, as a rule, should then be stopped. Long-term psychological care or psychiatrist
care based on HBS alone is contraindicated. One year after the initial diagnosis of HBS, SAS can be completed
providing the patient meets the requirements for surgery noted below.
In the absence of any other medical, surgical, or
psychiatric conditions, basic medical monitoring should include:
(1)
Regular
physical examinations relevant to treatment effects and side effects.
(2)
Vital
sign measurements before and during treatment
(3)
Weight
measurements and laboratory assessment.
For females receiving estrogen treatment, the minimum
laboratory assessment should consist of a pretreatment free testosterone level,
fasting glucose, liver function tests, and complete blood count, with re-assessment
at three month intervals and annually thereafter. A pretreatment prolactin level should be
obtained and repeated at 1, 2, and 3 years. If hyperprolactemia does not occur during this time, no further
measurements are necessary.
Females should also be monitored for breast cancer and strongly
encouraged to engage in routine breast self-examination. As they age, they should be monitored for
prostatic cancer.
For males receiving androgens, the minimum laboratory
assessment should consist of pre-treatment liver function tests and complete
blood count with reassessment at 3-month intervals and yearly
thereafter. Yearly palpation of the
liver should be considered. Patients
should be screened for glucose intolerance and gall bladder disease.
Males who have undergone mastectomies who have a family
history of breast cancer should be monitored for the disease.
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
her/his gender. Dissatisfaction with
hormonal effects may signal ambivalence about proceeding to surgical
interventions.
In females, hormones alone often generate adequate breast
development, precluding the need for augmentation mammaplasty.
XIV.
Requirements for Sex
Affirmation Surgery and Breast Surgery:
Prior to obtaining SAS or breast surgery, the following
minimum guidelines are strongly encouraged. While many may feel these guidelines are too rigid of an imposition,
they nonetheless give both patient and caregiver ample opportunity to assess
the correctness of the HBS diagnosis. It is understood that, as with any medical treatment protocol, the process
of assessment and validation may reveal the need for departures from the norm.
Recommended requirements for SAS or breast surgery are:
(1)
One
year on Hormone Replacement Therapy after HBS diagnosis.
(2)
One
year of successful continuous full time living in her/his affirmed sexual
identity.
(3)
Awareness
of the cost, required lengths of hospitalizations, likely complications, and
post surgical rehabilitation requirements of various surgical approaches before any procedures are begun.
(4)
Awareness
of the options of different competent surgeons.
(5)
Physician
consent form for surgery.
Sex Affirmation Surgery is the most important and effective
treatment to correct the underlying problem of HBS. The surgeon should be a gynecologist, urologist, 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 is 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 only 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 at least 24 hours in advance of surgery.
XV.
Genital, Breast, and Other Surgery
for the Female Patient.
(1)
penile
skin inversion
(2)
pedicled
rectosigmoid transplant
(3)
free
skin graft to line the neovagina
Augmentation mammaplasty should be performed prior to
vaginoplasty only after the physician prescribing hormones, the surgeon, and
the HBS patient consensually agree that natural breast development 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:
(1)
reduction
thyroid chondroplasty
(2)
suction-assisted
lipoplasty of the waist
(3)
rhinoplasty
(4)
facial
bone reduction
(5)
face-lift
(6)
blephoroplasty
Patients who elect voice modification surgery should do
so after all other surgeries requiring general anesthesia with intubations are
completed inorder to protect their vocal cords.
XVI.
Breast and Genital Surgery for the
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
maturation, 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 indicates that further technical
development is necessary. Patients may
undergo hysterectomy and salpingo-oophorectomy prior to phalloplasty.
XVII.
HBS along with other conditions.
XVIII.
Artificially Induced HBS.
One situation in which the cause of Harry Benjamin's
Syndrome is quite clear is the sexual mutilation of children or infants. This
most often occurs with intersex infants whose genitalia are ambiguous. It is common practice that the intersex
infant is operated on to make them conform more closely to a sex arbitrarily chosen
by a doctor or parent, with no possibility of consent or regard for the
infant’s brain structure or gender identity.
It can also occur if a male infant’s penis is accidentally
mutilated or severed, and where it is deemed easier to surgically transform him
into a female than to reconstruct or reattach the penis.
Research, as well as anecdotal evidence from the affected
people themselves, has disclosed that people in these situations are, as a
rule, unhappy living with the results of presumptuous and arbitrary decisions wrongly
made on their behalf. It is not
uncommon for them to seek out and revert to their actual gender (true brain
sex) later in life.
This tragic scenario can, and should, be avoided by allowing
the child to develop and mature autonomously to the point where self-actualization
of his or her true sex can be realized. Only then, with commensurate precautions having been ensured, should
appropriate corrective surgery be undertaken.
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[Terminology] [Standard of Care (SOC)] [Definition]
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