Sir: I read with interest the paper by Murjan, Shepherd and Ferguson (Reference Murjan, Shepherd and Ferguson Psychiatric Bulletin June 2002, 26, 210-212).

In their assessment of services provided to transsexual patients, the authors relied on the 5th edition of the Harry Benjamin International Gender Dysphoria Association Standards of Care for Gender Identity Disorders (1998). In doing so they omitted to refer to the current edition which is the 6th edition, (2001), with revised standards and a modern approach favouring flexibility, rather than uniformity of provision. The current edition concludes that “in some patients, hormone therapy alone may provide sufficient symptomatic relief to obviate the need for cross-living or surgery”.

The unfortunate consequences of the authors' use of the old edition are manifest in two ways. First, their implicit criticism of a Health Authority for commissioning hormonal therapy without surgery for transsexual people; and second their statement that “management [of transsexual patients] includes… the real ‘real life experience”’ (“cross-living”). In similar vein, Ferguson (Reference Ferguson2002) recently proposed a ‘uniform’ national standard of care which stated that “the person will be expected to enter the Real Life Experience” and envisaged hormonal support (for male to female transsexuals) for no more than 3 months unless the patient committed to cross-living full-time.

The use of hormone therapy can sometimes suffice to spare transsexuals the medical and legal consequences of surgery or cross-role living, and accords with the principle of least intervention. The transsexual opting for surgery faces a battle with osteoporosis, yet the authors presented no data about the availability of endocrinological postoperative support.