Monday, January 10, 2011

"The Standards of Care" debate

Let's talk about Dr. Harry Benjamin a bit. When he developed the set of criteria known as the Harry Benjamin Standards of Care, (HBSOC) it was a different time. At that time homosexuality was considered a mental aberration, and gay men often tried to get SRS to get "cured" of their affliction. Of course this didn't work, and so some standards were required to determine if someone was looking for SRS for the right reasons. The standards have changed only slightly since then, and of course there are people calling for far more substantive change or even their elimination. This is complicated by the fact that it is a lot cheaper to go to another country to get the same surgery and without these hoops created by the HBSOC.

And here we get the camps again. There are a lot of "TSDIY" groups out there who call for the elimination of psychological exams and other steps before SRS. And there are the folks, mostly surgeons, therapists, and those who have already undergone the procedure, who feel that any change, much less elimination, will provide access to massive hoards of folks who are unfit to so much as don a pair of pantyhose, much less undergo SRS.

The HBSOC, often referred to as The Standards of Care, have advantages and disadvantages. For one thing, they slow the process down a lot. This is both a good thing and a bad thing. It's good because it keeps people from doing something on a whim they can't reverse, and in our litigious society chances are good that they won't take full responsibility for their actions, choosing to sue the surgeon instead. But often GID is an acute problem, at least subjectively, and there is no good reason to extend someone's suffering if they can be cured more quickly. Of course since GID carries other disorders as passengers, it is important to deal with these first to clear the patient's mind enough so they can determine what level of change they require, but any longer than that borders on harm instead of help. It's sticky, to be sure.

The big problem is that this costs money. Just with the prices in the United States for surgery, along with the side treatments of electrolysis or laser hair removal, and subsidiary surgeries that are all too common like Facial Feminization Surgery, (FFS) nose jobs, adam's apple shaves, and breast augmentation, the price is already sky high. Add in a drug or drugs not covered by any health plan, (Transsexual and Transgender drugs aren't covered on any plan I know of) and then tack on a whole new wardrobe, (Often in odd sizes) and it gets even more expensive. This explains a lot why many folks seeking SRS wind up as (often illegal) sex workers. But to add years of therapy on to it just pushes the costs higher.

So, what do I think is the answer? With the possibility that GID is about to go completely away in the DSM-V the surgeons performing this surgery will have to set their own standards. I suspect most will still require the Standards of Care as a guideline, though there is already some defection from the ranks. (One surgeon will accept a longer Real Life Experience as a replacement for the two letters from a therapist) I'd prefer one letter that basically stated that the person is healthy enough psychologically to undergo the surgery. (I'd like to see this for all elective surgeries, in fact, because people mess themselves up a lot with these surgeries) And I think the surgeon requiring some crossliving time to be a good thing.

If I had my way there'd be a measured plan for someone to work toward their goals, first starting with something like a Tri-Ess chapter or other crossdressing club, and moving toward shopping experiences, then more intense experiences, so that they can work their way into their comfort level. Then I'd suggest about a year of crossliving using a DBA or other identification that isn't permanent, (getting something to allow this passed would be a good thing) so they can find their level. Then if they're still not happy it's time to talk to a surgeon and do the final psychological workup, most likely including an MMPI for empirical results.

I'd also like to see some buy in from society and our identification resources. If I had my preference the gender marker would go away on birth certificates, school records, drivers licenses, and just about every other piece of identification, as it opens the doors to too much discrimination and serves no real good purpose. Such designations stand in the way of gender equality and a discrimination free society.

I continue to believe very strongly that dealing with the other problems will alleviate much of the pain a GID sufferer experiences, and that these should be dealt with before facing the gender issue because they influence and confound it. A person who got SRS and has Borderline Personality Disorder, for example, isn't going to be happier after the surgery, Because the BPD is still there and is a very serious problem.

This is just my view. I'm open to hearing other viewpoints, so if you have them email me and we'll talk.


Anonymous said...

The HRT medications are covered under several health insurances, and now even surgeries are more widely covered by health plans.

Kayleigh said...

Thank you, Anon! I personally wasn't aware that that was the case. Nifty.


abNorma said...

My question is -

Will these medical plans cover Estrogen HRT for a genetic male? This seems to violate most of their historically exclusionary language for anything relating to Transgendered or Transsexual issues.

I have a feeling some of this will change if the APA drops GID (Gender Identity Disorder) from the DSM-V completely, but if they don't, we'll still encounter resistance.

Thanks for the comment. I'll be looking around for more information on this, because it does indicate a positive improvement for those in this boat.