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Harry Benjamin

Harry Benjamin (1885–1986), a German-American endocrinologist, laid the foundation for current medical transgender care in 1966 with The Transsexual Phenomenon and the "Benjamin Scale" — a foundation that has never been empirically validated.

The Transsexual Phenomenon (1966)

From the 1940s onwards, Benjamin treated patients with cross-gender desires in New York. His 1966 book The Transsexual Phenomenon was the first large work describing the affirmative treatment path he pioneered (source). That path was later anchored in WPATH SOC. The idea behind it, an inner gender that does not match the body, is a metaphysical claim without a marker, test, or measurable basis.

That choice has never been tested against psychotherapeutic alternatives in a randomised trial. According to the Cass Review, there are hardly any randomised controlled trials in children and young people receiving endocrine treatment, and the field is 'an area of remarkably weak evidence' (source) — a gap that still undermines the evidence base. Stephen Levine (2021) argues for a comprehensive evaluation and calls it relevant and ethical to explore which biological, social and psychological forces led someone to adopt a new identity (source). Yet Benjamin's paradigm became the global standard.

The Benjamin Scale: self-report as a method

The Sex Orientation Scale (SOS) divided "transsexuality" into six categories, from transvestite (type I) to "high-intensity true transsexual" (type VI). Categorization was based on clinical intuition and patient reporting. No objective criterion, no measurable marker — a textbook example of self-reporting as a source that would later dominate the entire field.

Blanchard (1989) proposed a different classification, the Blanchard typology: homosexual versus non-homosexual transsexuals, in whom he linked gender dysphoria to autogynephilia. In his study of 212 male-to-female transsexuals, all three non-homosexual groups reported more sexual arousal with cross-gender fantasy than the homosexual group (source). Later studies supported the typology only in part (Nuttbrock et al., 2011 (source); Veale, 2014 (source)). Benjamin's scale is outdated as a research instrument.

HBIGDA and the birth of WPATH

In 1979, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) was founded — the direct predecessor of WPATH. Its Standards of Care were largely based on Benjamin's cases (source). The model spread in the American and European rollouts — including in the Netherlands, where, according to the Cass Review, the Dutch Protocol was developed by Peggy Cohen-Kettenis, founder of the Utrecht gender clinic, and later adopted internationally (source).

The BMJ reported on 31 October 2024 that Johns Hopkins researchers who carried out evidence reviews for WPATH wrote that the commissioning body tried to restrict their ability to publish; WPATH denied this (source) — see also the WPATH Files (2024). SBU (2022) found the evidence for hormone treatment of young people insufficient, and NICE (2020) rated it of very low certainty. The Cass Review (2024) calls the field 'an area of remarkably weak evidence' (source).

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