By Dr Tracie O’Keefe DCH December 2000, published in Gendys Journal, UK
For many years the Harry Benjamin International Gender Dysphoria Association (HBIGDA) has recommended Standards of Care (SOC) to practitioners treating and helping people with sex and gender dysphoria.
Many doctors, psychiatrists, psychologists, therapists and endocrinologists have fought for and taken a great deal of notice of these standards in order to afford their clients the best possible care.
However, some practitioners who are not members of HBIGDA rarely know what those standards are or choose to ignore them. There have also been members of the HBIGDA who have ignored the SOC or never even bothered to read them, affording their clients deficient care.
At the end of the day having SOC that were unenforceable was like having a dog with no bark. What HBIGDA has been missing is a code of ethics that is applicable to all member practitioners and institutions so that the clients can be sure that those SOC are being applied, adhered to and not abused. But HBIGDA is an international organisation of members from many disciplines, cultures and continents, whose theoretical, philosophical, moral, and social development and standards differ considerably.
I underwent a sex and gender transition some 30 years ago in England and had a really bad time. The psychiatrist, now dead, who treated me was madder than a March hare, and often abused his clients. He kept me waiting seven years for surgery and never failed during that whole time to be rude, arrogant and denigrating towards me. He continually wrote love letters to one of my fellow patients and supplied her with heroin as long as there was some promise she would become his lover. Several of my friends did not survive the abuse he foisted upon them under the guise of treatment and committed suicide.
Two years ago a doctor from the west coast of the USA, who had been struck off, was committed to prison after illegally operating on many desperate transpeople, ruining their bodies and lives. He carried on his butchery for many years with his potential clients being unaware of the danger in which they were placing themselves. The average person in the street often does not know how to check out doctors, surgeons or therapists to see if they are properly qualified and regulated.
Surgery is a risky business because due to the fact that so few surgeons operate in the field of sex and gender transformation it is impossible to truly monitor standards. One must rely on surgeons publishing their results openly and honestly and that is not always the case. The only common existing international connection between them is HBIGDA. If HBIGDA then fails to ensure that surgery is carried out to certain standard, what chance have the clients got?
Another client recently shot her therapist and herself after spending a year in psychotherapy and being refused hormones. I also had a client a few months ago who had been under a psychiatrist in the UK for four years and was still not being given hormones, because they were unable to fulfil the psychiatrist’s idea of a stereotypical woman.
Endocrinologists, too, are very difficult to work with as many of them simply do not want to carry transpeople’s case-loads because they fear there may be stigma that might discourage their other business. Neither do many of them bother to carry out sufficient research into gender medicine to give their clients the kind of treatment that is in line with up to date treatment.
I know and you know that the SOC are not perfect but they are an ever evolving improvement of the kind of treatment that went before, in line with what the client group wants, needs or desires. The clients do not always agree with the SOC and the gender community is constantly lobbying organisations like HBIGDA to catch up with developments in social philosophy and freedom for the individual to choose their own path in life. Academia admittedly is sometimes the last sector to realise or react to what is going down on the street but it must be allowed to set a benchmark by which to set the SOC for transpeople. If this were not to happen then there would be no SOC at all. I have been there and, believe me, it is not pretty.
There is little doubt that HBIGDA was set up originally in the early 1970s as an old boys’ club for those clinicians practising in the field of gender medicine, and some of the old boys are still there. They partly wanted a professional association and accreditation to stop themselves being sued when working in the field. But the organisation has evolved to be much more than that. It has become a forum for research, skills sharing and providing information to fuel the fight for equal, lawful treatment of transpeople worldwide. As attitudes to global medicine have changed and become more holistic, so has HBIGDA.
At the 1999 HBIGDA conference in London, when I talked about many members pissing on the SOC and assured the members that the gender community would not allow the repathologisation of sex and gender expression, I saw senior members of the board place their heads in their hands. The next day the new ethics committee was formed and in September 2000 the code of ethics came into being, binding all members to practise according to the SOC. Change can happen most effectively from within as well as pressure from outside.
The fight as to whether sex and gender identity changes are a pathology or a variation of nature’s physical and social expression still rages within HBIGDA and we must ask ourselves who stands to profit by such debates and stances. But also within HBIGDA are many dedicated, inspirational and deeply caring professionals who work far beyond the call of duty or profession to make a better world for the trans, and sex and gender variant people throughout the world.
So the path is now clear for clients who have consulted members of HBIGDA on a professional basis to lodge a complaint to the ethics committee if that service was not up to standard. The ethics committee will then investigate the complaints and if it is upheld the association will be empowered to place its own sanctions on the practitioner concerned. The practitioner will of course be given an opportunity to defend the complaint and also present evidence. Another duty of the ethics committee is to advise on enquiries of ethics and good practice.
Although any sanctions will be limited to HBIGDA membership, this could serve as an even greater benchmark in the SOC. Clients can be more confident in consulting a practitioner who is a member of HBIGDA who will be bound to practise according to the SOC, and they will know if they do not get a reasonable service they may seek the help of the ethics committee.
It is my sincere hope that members of HBIGDA and the public will take the introduction of the code of ethics to heart and be more confident in trusting us to do our jobs to a standard that can help people lead a more fulfilled life. The commercialisation of the sex and gender transitioning industry has meant that a wealthy individual can now simply travel and choose to get the kind of treatment they want, need or desire. However, for the economically disadvantaged they are often still held ransom to less than reasonable SOC previously without recourse for any distress they have suffered.
Unfortunately we cannot do anything about unethical practitioners who are not members of the HBIGDA, but we would still like to hear about them. Information is power and it is useful for us to know what is going on in the world in order to find the best ways forward for good SOC to be set in the future.
A list of and details to contact any member of the HBIGDA ethics committee can be found on our website at
Initially telephone or e-mail enquiries can be a first point of contact if a person wishes, but official complaints about practitioners must be in writing with as much printed and verified evidence as can possibly be provided. Oral evidence must always eventually be turned into a written statement in order for us to process information coherently to all committee members.
Since ethics committee members are scattered around the world then it does take some weeks or months for us to investigate a complaint fully. We welcome public input into attaining and maintaining SOC for all trans, sex and gender variant people we treat and help.