First Standards of Care; Johns Hopkins Stops Performing Surgeries

The year 1979 saw two opposing developments. Practitioners from several countries founded a professional association and, for the first time, established the standards that care had to meet. At the same time, the clinic where treatment had begun in the United States stopped performing surgeries.

The First Standards of Care

In February 1979, participants at an international symposium in San Diego approved the first Standards of Care. Their authors formed the Harry Benjamin International Gender Dysphoria Association, named after Harry Benjamin. The guidelines set conditions for hormone treatment and surgery, including assessments from behavioral health professionals and a period during which patients had to live in their desired gender role. A year later, transsexualism was included in the manual of psychiatric diagnoses; see the 1980 DSM-III.

The Meyer and Reter Study

In August 1979, psychiatrist Jon Meyer and Donna Reter of Johns Hopkins published a follow-up study of fifty patients. They compared people who had undergone surgery with those who had not. They concluded that surgery produced no demonstrable benefit in terms of social functioning.

The End of the Baltimore Clinic

Shortly afterward, Johns Hopkins stopped performing sex reassignment surgeries. Paul McHugh, head of the psychiatry department, was an outspoken opponent of the treatment. The study drew considerable criticism, including over the way functioning had been measured. Other American university clinics also closed in the years that followed, and care shifted to private practices. Johns Hopkins did not resume treatment until 2017.

The Physician as Gatekeeper

The first Standards of Care were based on the model that later became known as the gatekeeper model. Patients could not choose treatment for themselves; a psychologist or psychiatrist had to determine that treatment was indicated and issue a written statement to that effect. Two such statements were required for surgery. The authors wanted to protect patients from rushed, irreversible procedures and physicians from liability at a time when the treatment was still controversial.

Later Versions

The guidelines have since been revised seven times. New versions followed in quick succession in 1980, 1981, and 1990, followed by versions in 1998, 2001, 2011, and 2022. With each version, the requirements became less restrictive. In Version 7, published in 2011, the requirement to live in the desired role for a period before being prescribed hormones was dropped, and greater weight was given to the patient's own choice. Version 7 also included extensive recommendations on puberty blockers for young people for the first time.

The Debate Over the Study

The Meyer and Reter study remains controversial to this day. The researchers measured functioning using a point-based scale that included employment, relationships, contact with the justice system, and psychiatric care. Critics argue that such a scale says little about whether patients themselves were satisfied, and that the groups being compared were not equivalent. Other research from those years showed that most patients who had undergone surgery did not experience regret. McHugh continued to reject the treatment and later described it as participating in a mental disorder rather than treating one. Supporters and opponents still cite what happened at Johns Hopkins as an example.

Significance

The association has been called WPATH since 2007, and its guidelines have become the global standard; see Version 8 of the Standards of Care. More than forty years later, the question Meyer and Reter raised—whether the treatment demonstrably improves patients' lives—has once again become central.