German Standards for the Treatment and Diagnostic Assessment of Transsexuals

Requirements for Somatic Treatment

• Requirements for Hormonal Therapy
• Requirements for Sex Reassignment Surgery

Requirements for Hormonal Therapy

• The following requirements must be fulfilled before recommending hormonal therapy:
• As a rule, the therapist must have known the patient for at least one year.
• The therapist has examined the diagnostic criteria.
• The therapist has reached the clinically based judgement that the three above-mentioned psychotherapeutic criteria ( the inner cohesion and stability of the gender of identification and it’s individual expression, the ability to live in the desired gender-role, and the realistic assessment of the possibilities and limits of somatic treatments) have been fulfilled.
• The patient has lived in the desired gender-role continuously for at least one year (so-called real-life experience).

If the requirements have been fulfilled, then the professional recommendation must be documented in the form of a written expert opinion.   
  

Requirements for Sex Reassignment Surgery

The following requirements, along with an evaluation of the diagnosis, must be fulfilled in addition to all criteria described in section 3 (Standards for psychotherapy/psychotherapeutic guidance) before issuing a professional recommendation:

• The therapist has been acquainted with the patient for at least 18 months.
• The patient has lived within the desired gender-role continuously for at least 18 months (so-called real-life experience).
• The patient has been treated hormonally for at least six months.

In cases where the professional recommendation for sex reassignment surgery has not been issued by the patient’s psychotherapist, the consulting therapist/assessor must be satisfied that the above-mentioned requirements have been fulfilled and that the psychotherapy has taken place.

The professional recommendation for sex reassignment surgery must come from a qualified therapist and be stated as that therapist’s expert opinion.

This expert opinion must include the following points:

• The therapist should clearly and intelligibly state that the diagnosis of transsexuality was confirmed in the course of treatment, i. e. it must be shown that the patient experiences a stable sense of identity in the opposite gender and that his behavior reflects a longterm adoption of the opposite gender’s role.
• A description of the patient’s appearance, behavior, and personality.
• A case history focusing on significant aspects of the individual course of transsexual development and influential factors in that development (including, where necessary information gathered from extraneous sources).
• The course of the treatment (with mention of length and frequency) should be presented, referring to realizations gained in the real-life experience. Especially important information is: a) when the real-life experience was begun, b) if and when a change of name as defined by the Code for Transsexuals was applied for or was granted and c) which changes have occurred in the following areas: psychological condition and balance, security in the gender role, sexuality, partner relationship, family , and friends, ability to work, and acceptance at place of work.
• The physical conditions of the patient’s life in the opposing gender role should be depicted. How the hormonal treatment affected him physically and psychologically as well as how the patient assesses the physical changes should be documented, including the ability to cope with possibly negative reactions in his environment to his outward appearance or behavior.
• Descriptions should include: a) if the patient has realistically come to terms with the operation and possible undesirable results, b) which specific expectations the patient emphasizes as resulting from the operation (for example appearance, function, or sexuality), and c) if he desires further invasive surgery after the operation in question.
• Explanations for why the patient would, over time, be subject to more severe suffering without surgery.
• A prognosis should be provided that shows the probable effects of gender reassignment surgery for the patient in the fields of social integration, ability to enter relationships, ability to work, and independence.