The most commonly-accepted protocol for counseling and preparing pre-operative transsexuals for sex reassignment surgery were established by the Harry Benjiman International Gender Dysphoria Association (HBIGDA) in 1979. The "Standards of Care," as they are known, recommend a three-step approach for pre-op transsexuals.

The first step involves "real life experience." Patients are expected to spend at least three months living in their chosen gender, without the benefits of hormones or surgery. Although the most recent (2000) version of the Standards of Care calls for only "episodic cross-gender living," it is widely understood by the medical community that the more a patient attempts to adjust to their chosen gender prior to the commencement of hormone therapy and surgery, the greater likelihood of successful adaptation to the patient's new gender role. In some instances, a minimum of three months of continuing psychotherapy can be substituted for the real-life experience.

Upon satisfaction of the real-life experience requirement, and with a letter of recommendation from a supervising mental health professional, the patient is then introduced to hormone therapy. The Standards of Care require a full 12 months of hormone therapy coupled with full-time cross-gender living. Retreats by the patient to their biological gender, even temporary ones, are seen as troubling indications of unreadiness for surgery.

The final stage of the protocol is actual sex reassignment surgery. (Note that "surgery" is usually used to refer to genital surgery. Surgery to either enhance or reduce breast tissue is considered far less severe under the Standards of Care. Generally, the protocol authorizes patients to obtain breast enhancement or reduction surgery in conjunction with hormone therapy.) Upon completion of a full year's hormone therapy, a patient must usually obtain two letters of reference: one from his or her regular psychotherapist, and a second from an independent, evaluating therapist, before obtaining surgery.

The HBIGDA protocol generally applies to adults, and the organization is very conservative about treating adolescent transsexuals. Only in exceptional circumstances do the Standards of Care permit hormone therapy for patients under age 18, and it recommends that real-life experience begin no earlier than age 16.

The HBIGDA protocol is considered by many transsexuals to be unnecessarily conservative and extended. In response to complaints from some transsexuals about the rigidness and length of the HBIGDA protocol, the International Conference on Transgender Law and Employment Policy (ICTLEP) has promulgated its own set of much-looser standards. In general, the ICTLEP standards have no fixed timeframes or procedures. In fact, the ICTLEP standards seem to require little besides true "informed consent" by the patient.

Because they are merely recommendations, the HBIGDA Standards are not always scrupulously followed, and can be modified or even waived in some cases. Therapists are much more willing to abridge the requirements for particularly well-adjusted patients.

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