Harry Benjamin
International Gender Dysphoria Association

A simplified guide to the Standards of Care



In 1979, a concerned group of psychologists, physicians, and other care givers met to formulate guidelines for the hormonal and surgical treatment of persons with gender dysphoria. The resulting Standards of Care have been regularly modified, most recently in 1998.

The standards provide a description of the basic steps a transsexual person should follow in seeking hormonal and surgical treatment.

Steps should be taken sequentially. There is no requirement to proceed further. It is entirely possible, for instance, to live as a member of the other sex without desiring or having genital modification surgery. Only if you desire additional medical procedures should you proceed to higher steps. It should be noted that there are as many female to male (F to M) transgender people as there are male to female (M to F) transgender people.

1. Diagnosis

Your first step is to see a licensed clinical behavioral scientist (psychologist, counselor, psychiatrist, or clinical social worker) with proven competence in the field. Evaluation must occur over a period of at least ninety days. During this period, you should talk about your feelings of gender dysphoria with your therapist and explore your options.

After this ninety day period, you should ask your therapist for his diagnostic impressions.

2. Obtain referral for hormonal therapy

At the end of the ninety day period, you can also ask your therapist for a referral to an endocrinologist for hormonal therapy. An experienced therapist will have a referral network of endocrinologists and other professionals. Typically, therapists contact the endocrinologist on your behalf.

It will be a good idea to maintain contact with your therapist. First, sex reassignment is at best a difficult process, and there may be times when it will be useful to speak to a therapist. Second, there may be times when additional authorization letters and referrals are needed. In either case, a therapist who is familiar with your progress will be better able to help.

3a. Consult an endocrinologist

Your endocrinologist should have proven competence in working with transgender people, for improper dosages of hormones can be dangerous. Hormones will cause gradual but progressive changes in your secondary sex characteristics (breast growth and lessening of body hair in M to F's, and lowering of voice, and increase in body and facial hair in F to M's), which will cause you to look more masculine or feminine over time. M to F's will additionally experience lowered libido and sterility, and F to M's will experience clitoral growth, increased libido, cessation of menses, and (sometimes) acne or male pattern baldness.

In M to F's, hormonal changes, with the exception of breast growth, are largely reversible. Beard growth, voice deepening, and clitoral enlargement in F to M's are not reversible.

Hormones for M to F's consist of estrogens, and sometimes progestins. Anti-androgens may also be given. Route of administration may be oral, intramuscular, via injection, or transdermal, via patches. Androgens are given for F to M's, usually intramuscularly.

All hormonal treatments require medical supervision.

3b. Start electrolysis (for M to F's)

M to F's will need electrolysis to remove facial hair. This procedure is more easily done while still living in the male role, as it requires a two-four day period of growth before treatment, and can result in skin inflammation. When living as a female, it is difficult to schedule enough time to allow facial hair to grow for treatment.

Body hair will decrease with time on hormones, but some electrolysis of the arms, legs, or torso may be desired.

4. Begin a period of cross living.

A major requirement of the Standards of Care is to live and work (or go to school, if a student) full time in the new gender role in order to achieve candidacy for genital surgery. During this "real-life test" you must dress and function in your new role 24 hours a day, seven days a week.

With sufficient time on hormones and (M to F's) electrolysis, appearance will change sufficiently to allow you to begin the real-life test.

You should think of the real-life test as an experiment. It is not an endurance contest, but an opportunity to experience what life is like in the new gender. The more thoroughly you experience this new life, the better your idea of what the rest of your life will be like. If you find it necessary to revert to your original role on occasion, if you experience public humiliation because of your appearance, or if you find the new role nerve wracking or uncomfortable, this is a sign that you should extend the period of real-life test. Only when you are comfortable in the role and have been so for a minimum of one year should you consider scheduling genital modification surgery.

5. Sex Reassignment Surgery

After the requirements of the real-life test have been met, you are eligible for evaluation for sex reassignment surgery.

Two authorization letters from therapists are required for sex reassignment surgery. Surgeons may have additional requirements.

For M to F's, surgery can consist of a simple castration, but more frequently, a neovagina is constructed from penile and scrotal tissue. Penile inversion surgery is the most common vaginoplasty technique. Some surgeons supplement penile inversion with a skin graft or skin flap, and others with a section of large or small intestine. For F to M's, "top" surgery consists of breast reduction. There are several options for "bottom" surgery. Genitoplasty (metadioiplasty) converts the testosterone-enlarged clitoris into a small phallus. In phalloplasty, tissue from other areas of the body are used to create a phallus. Labia may be fused to form a scrotum, with silicon testicular implants.

Other Procedures

M to F's may desire additional plastic surgical procedures, such as breast implants, rhinoplasty (nose reduction), tracheal shave, hair flap surgery, or facial or body recontouring. Females may seek electrolysis on ares of the body which will be used as donor sites for phalloplasty. These procedures may be obtained at any time after the initiation of hormonal therapy. It is a good idea, however, to delay breast augmentation for at least two years after initiation of hormonal therapy, to allow for natural breast development.


Costs of medical treatment vary greatly. Many insurance companies specifically exclude many of the treatments associated with sex reassignment surgery. Typically the individual must bear many costs himself or herself. Indirect costs (loss of employment, legal costs like alimony and child support, etc.) can run far more than direct costs. By comparison shopping and in general being a good medical consumer, you can minimize direct costs. Careful planning can minimize indirect costs.


Friends, family, sexual partners, and co- workers may or may not be supportive - but are sure to need information and support as well.

Sources for support include helping professionals, support groups, and information services like the Gender Education Center & AEGIS. You should avail yourself of as many as possible.



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