We now know that the brain is the only part of the body that can define one’s sex. Therefore, one's true sex is determined by the structure of the brain, not by the genitalia. Gender identity is hard-wired in the brain and in deeper CNS structures. The main difference between Harry Benjamin Syndrome and some other intersex conditions is that there is no apparent evidence at the moment of birth making it possible for doctors to diagnose it.

IV. Epidemiological Considerations.

It is believed that 1 child out of every 100.000 is born with Harry Benjamin Syndrome.

V. Diagnostic Nomenclatures.

Harry Benjamin Syndrome was known in the past under many different names, Transsexualism being the most common. Some have even added transsexualism as a sub-set of transgender and that of course was never intended to be included under that umbrella term when transgender was coined. However, Harry Benjamin Syndrome is not Transsexualism (or any variation of Transgenderism). At least not under the current definition of Transsexualism provided by the ICD-10.

Harry Benjamin Syndrome is still incorrectly classified as Transsexualism today by the ICD-10. “Transsexualism” is classified as a mental disorder with a psychological cause. Harry Benjamin Syndrome is a physical condition indicative as a fetal anomaly. There is no relationship between these conditions. Maintaining such an outdated policy only denies patients with Harry Benjamin Syndrome adequate medical care and societal understanding. It can also often place them under the inappropriate medical standards of care.

In 1980 Transsexualism was introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and fourteen years later, in 1994 it was changed to Gender Identity Disorder (DSM-IV). It is supposed to be revised again in 2013 for DSM-V. 

We hope that the condition will be named Harry Benjamin Syndrome for the reasons we explain in the next section. We strongly urge to remove Harry Benjamin Syndrome from the Diagnostic and Statistical Manual of Mental Disorders.

We propose these differentiated levels of diagnosis:

-HBS in Children (below age 12)
-HBS in Adolescents (below age 18)
-HBS in Adults.
-HBS along with other intersex conditions.
-HBS along with other neurological conditions.
-HBS not otherwise specified.





VI. Classification and Terminology.


Harry Benjamin Syndrome is a neurologically intersex condition and as such must be classified, as an Intersex condition not as a mental disorder. Should Harry Benjamin Syndrome be denied as an intersex condition classification then it should be classified among other rare medical conditions not related to any mental disorder.

Harry Benjamin Syndrome is named in honor of Dr Harry Benjamin, a pioneer in the research of this condition. He was the physician who contributed much to the understanding and recognition of this condition. It was through his efforts the entire medical community came to understand HBS was unrelated to homosexuality. Harry Benjamin Syndrome, (HBS), is greatly preferable to other terms because it lacks the misleading connotations and inaccurate meanings they possess.

Basic Terminology associated with Harry Benjamin Syndrome:

Harry Benjamin Syndrome. (HBS)
Hormone Replacement Therapy. (HRT)
Sex Affirmation Surgery. (SAS)

Affirmation and Affirmation’s process.

Intersex, Intersexed, Intersexual. (IS)



Reflections about other terminologies commonly used in the past:


a. Transsexualism – Transsexuals.

The most well-known term for Harry Benjamin's Syndrome is Transsexualism (coined by sexologist Magnus Hirschfeld in the 20's). Unfortunately there are several problems with it. Simply including "sex" in the name attracts undesirable attention, and the word strongly implies a connection with sexual orientation that does not exist. It's too similar to "transvestism", a completely unrelated phenomenon (men who enjoy wearing women's clothing don't have much in common with men who were born with female anatomy and are very unhappy about it) that bears enough of a superficial similarity to cause much confusion. Also, labelling people with Harry Benjamin's Syndrome with the term "transsexual" is a bad thing. Saying that people are transsexuals is dehumanizing, and makes it easier to think of them as being "other". People with Harry Benjamin's Syndrome are people, who happen to have a particular medical problem; it is not their identity, and they are not specimens of the condition. Use as an adjective is not much better; with "transsexual man" or "transsexual woman", it's too easy for "transsexual" to be interpreted as "pretend", and for some reason many people seem to be confused about whether the appropriate noun for any particular individual is "man" or "woman".

The term "transsexual" is a combination of two words: "trans" + "sexual".
The word "trans" is a Latin prefix which means across, beyond, through, so as to change. In modern English it means on, or to the other side of, across, beyond. The word "sexual" is an adjective derived from the Latin sexualis, and it means of, relating to, or associated with sex or the sexes. When these two words are combined, the reason the term has been applied to some individuals becomes apparent. Now well, those called "transsexuals", must make many adjustments to overcome difficult obstacles. Somehow it seems unfair to burden people with labels which no longer seem appropriate when they have made changes, adjustments, overcome obstacles, had surgery, and taken their places in society in roles in which they are comfortable. In their minds, it is no longer a question of being between or crossing between the sexes, as the term "transsexual" implies. And certainly, at that point, they have not need not desires to have surgical alteration of their genitals. If others needs to refer to them for the purpose of identification, then they should use the terms "woman" or "man".

b. Transsexuality.

There is a great stigma associated to Transsexuality: This is considered to be a "lifestyle choice" for many people or even a kind of "expansion" of one's personality, and the term "transsexuality" itself reinforce even more this so deeply rooted stigma about Harry Benjamin's Syndrome. That's why the findings of biological markers for the syndrome in parallel with the update of the terminology in use, are so liberating. Transsexuality is a natural phenomenon in the animal kingdom and is there where to speak about transsexuality or transsexuals is adequate, but it is not adequate to use this same terminology with human beings, with persons. Simply because the persons aren't amphibious changing sex continually in a "natural" way, and of course is not a choice they made neither. People with Harry Benjamin's Syndrome do not change sex, they don't become the opposite sex, they already are of a determined sex -determined by its brain structure, which already is how it should be, and it cannot be "changed".

c. Transgender.

"Transgender" has become popular recently as an all-inclusive term for a wide variety of extremely disparate groups, especially amongst the queer community This is not a positive development, as it is far too broad a category to say anything useful, and implies similarities that do not exist. It's like having a word that means "plays chess, is asian, or has cancer" - using it to descibe someone tells you nothing about them.

And about the preference to use SAS (Sex Affirmation Surgery) above other terms:

The term "Sex Affirmation Surgery" (SAS) is preferable to the alternatives of "Sex Reassigment Surgery" (SRS) or "Gender Reassignment Surgery" for describing the operation used to help correct the anatomies of people with Harry Benjamin's Syndrome. There is certainly no reassignment of gender involved, and it only involves one aspect of physical sex, which is not a binary, either-or characteristic. The sex of the brain is already as it should be, and HRT corrects other sexual characteristics. For men, HRT can even go a little way towards correcting the genitalia, though nowhere near the complete development that occurs in the womb. It is about Affirmation (or correction of a physical defect), not about transition or change.

VII. Requirements for Professionals.


The following are the minimal credentials for special competence with HBS:

1. Doctorate degree of Medicine (MD).
2. A master’s degree or its equivalent in a clinical behavioral science field.
3. Specialized training and competence in the assessment, management and
treatment of Harry Benjamin Syndrome (not in transgenderism).

4. Continuing education in the treatment of Harry Benjamin Syndrome which
may include attendance at professional meetings, wokshops, or seminars, or
participating in research related to Harry Benjamin Syndrome.

VIII. Diagnosis and Treatment.


Psychological follow up is very useful for a proper diagnosis of this condition and its physical treatment afterwards can correct it completely. The early treatment of Harry Benjamin Syndrome can eliminate virtually all the symptoms of the condition although it can be reasonably assumed that having suffered the long terms effects of untreated Harry Benjamin Syndrome may result in the need for some proper and effective counseling to eliminate or diminish the lingering and possibly damaging after effects.

In order to properly realign the person’s body to its proper brain sex the treatment will include Hormonal Replacement Therapy (HRT) and Sex Affirmation Surgery (SAS).

Most of the medical community of today is perfectly prepared to successfully treat Harry Benjamin Syndrome but is still lacking the quality diagnosis caused by the lack of information and research updates about this condition therefore leaving doctors equating treatment with the myths of the past.

It is advisable to visit an endocrinologist and give him or her up to date information about Harry Benjamin Syndrome, this way you will be opening the door to receive more objective treatment. In most cases, it is difficult to give a diagnosis before late infancy or pre-adolescence, although countries like the Netherlands are very advanced in diagnosing and treating this syndrome. Thanks to the hard work of Cohen-Kettenis, people living in the Netherlands are able to start the treatment before puberty.

It’s important to remind everyone that Harry Benjamin Syndrome is a physiological condition and not psychiatric, even though the help of a psychologist can be very useful for the patient, especially the younger ones in the initial evaluation and proper diagnosis. The treatment of this condition includes HRT and SAS. Visiting a psychiatrist or a therapist for evaluation should be required but not as a long-term treatment parameter unless other issues not related to HBS exist. Then if the patient is diagnosed as having HBS then the patient should be referred to an endocrinologist for hormone preparation for SAS followed by referral to a competent surgeon.

Long-term psychological follow up (other than for diagnosis purpose only) and any kind of psychiatrist treatment are strongly contraindicated for patients with HBS unless there are other issues that need to be resolved.

XI. Treatment of HBS in Adults.

After diagnosis of HBS is complete, HRT can be immediately started. Psychological follow up should be then stopped. Long-term psychological care or psychiatrist care based on HBS alone is contraindicated. One year after the initial diagnosis of HBS, SAS can be done if the patient meets the requirements for surgery noted below.

Hormone Replacement Therapy plays an important role in the anatomical and psychological sex affirmation process for properly selected adults with HBS. These hormones are medically necessary for rehabilitation in their affirmed sex. When physicians administer androgens to males and estrogens, progesterone, and/or testosterone-blocking agents to females, patients feel and appear more like members of their true sex.

After a thorough medical history, physical examination, and laboratory examination, the physician should again review the likely effects and side effects of this treatment, including the potential for serious, life-threatening consequences. The patient must have the cognitive capacity to appreciate the risks and benefits of treatment, have his/her questions answered, and agree to medical monitoring of treatment. In the absence of any other medical, surgical, or psychiatric conditions, basic medical monitoring should include: serial physical examinations relevant to treatment effects and side effects, vital sign measurements before and during treatment, weight measurements, and laboratory assessment. For those receiving estrogens, the minimum laboratory assessment should consist of a pretreatment free testosterone level, fasting glucose, liver function tests, and complete blood count with reassessment at 6 and 12 months and annually thereafter. A pretreatment prolactin level should be obtained and repeated at 1, 2, and 3 years. If hyperprolactemia does not occur during this time, no further measurements are necessary. For those receiving androgens, the minimum laboratory assessment should consist of pretreatment liver function tests and complete blood count with reassessment at 6 months, 12 months, and yearly thereafter. Yearly palpation of the liver should be considered. Patients should be screened for glucose intolerance and gall bladder disease. Females undergoing estrogen treatment should be monitored for breast cancer and encourage in engage in routine self-examination. As they age, they should be monitored for prostatic cancer. Males who have undergone mastectomies who have a a family history of breast cancer should be monitored for the disease.

Hormonal treatment, when medically tolerated, should precede any genital surgical interventions. Satisfaction with the hormone's effects consolidates the person's identity as a member of her/his gender. Dissatisfaction with hormonal effects may signal ambivalence about proceeding to surgical interventions. Hormones alone often generate adequate breast development, precluding the need for augmentation mammaplasty.

Requeriments for Sex Affirmation Surgery and Breast Surgery:


1. Six months on Hormone Replacement Therapy after HBS diagnosis.

2. One year of successful continuous full time living in her/his affirmed sexual identity.

3. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches.

4. Awareness of different competent surgeons.

5. A physician consent form for surgery.

Sex Affirmation Surgery is the most important and effective treatment to correct the underlying problem of HBS. The surgeon should be a urologist, gynecologist, plastic surgeon or general surgeon, and Board-Certified as such by a nationally known and reputable association. The surgeon should have specialized competence in genital reconstructive techniques as indicated by documented supervised training with a more experienced surgeon. Even experienced surgeons in this field must be willing to have their therapeutic skills reviewed by their peers. Willingness and cooperation with peer review are essential. This includes attendance at professional meetings where new ideas about techniques are presented.

Ideally, the surgeon should be knowledgeable about more than one of the surgical techniques for genital reconstruction so that the surgeon will be able to choose the ideal technique for the individual patient's anatomy and medical history. When surgeons are skilled in a single technique, they should so inform their patients and refer those who do not want or are unsuitable for this procedure to another surgeon.

Prior to performing any surgical procedures, the surgeon should have all medical conditions appropriately monitored and the effects of the hormonal treatment upon the liver and other organ systems investigated. This can be done alone or in conjunction with medical colleagues. Since pre-existing conditions may complicate genital reconstructive surgeries, surgeons must also be competent in urological diagnosis. The medical record should contain written informed consent for the particular surgery to be performed.

Genital, Breast, and Other Surgery for the Female Patient.

Surgical procedures may include orchiectomy, penectomy, vaginoplasty and augmentation mammaplasty. Vaginoplasty requires both skilled surgery and postoperative treatment. The three techniques are: penile skin inversion, pedicled rectosigmoid transplant, or free skin graft to line the neovagina. Augmentation mammaplasty may be performed prior to vaginoplasty if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormonal treatment for two years is not sufficient for comfort in the social gender role. Other surgeries that may be performed to assist feminization include: reduction thyroid chondroplasty, suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction, face-lift, and blephoroplasty.  Voice modification surgery:  Patients who elect this procedure should do so after all other surgeries requiring general anesthesia with intubation are completed to protect their vocal cords.

Breast and Genital Surgery for the Male Patient.

Surgical procedures may include mastectomy (chest reconstruction), hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, and phalloplasty. Current operative techniques for phalloplasty are varied. The choice of techniques may be restricted by anatomical or surgical considerations. If the objectives of phalloplasty are a neophallus of good appearance, standing micturition, sexual sensation, and/or coital ability, the patient should be clearly informed that there are both several separate stages of surgery and frequent technical difficulties which require additional operations. Even the metoidioplasty technique, which in theory is a one-stage procedure for construction of a microphallus, often requires more than one surgery. The plethora of techniques for penis construction indicate that further technical development is necessary. Patients may undergo hysterectomy and salpingo-oophorectomy prior to phalloplasty. The mastectomy procedure is usually the first surgery performed, but for some patients it is the only surgery undertaken. When the amount of breast tissue removed requires skin removal, a scar will result and the patient is informed.

Long-term follow-up with the surgeon is recommended in all patients to ensure an optimal surgical outcome. Surgeons who are operating on patients who are coming from long distances should include personal follow-up in their care plan and then ensure affordable, local, long-term aftercare in the patient's geographic region. Postoperative patients may also incorrectly exclude themselves from follow-up with the physician prescribing hormones, not recognizing that these physicians are best able to prevent, diagnose and treat possible long term medical conditions that are unique to the hormonally and surgically treated. Postoperative patients also have general health concerns and should undergo regular medical screening according to recommended guidelines.