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Surgery Referrals – GenderGP

Many patients are faced with barriers when they are trying to access gender-affirming surgery. Surgeons are often anxious about performing irreversible procedures on patients who may later not achieve their desired outcome and be dissatisfied with their results. Hence, surgeons can make requests from doctors and psychiatrists to perform assessments and to endorse the recommendation for surgery. As the pool of doctors and psychiatrists working in this field in the UK is small, and as their assessments and reports can be expensive, we are looking at other options to make surgery referrals more affordable for trans people.

Healthcare professionals look to the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) for assistance, and this document references this guidance.

Who qualifies for surgery?

WPATH – ‘While the SOC allow for an individualized approach to best meet a patient’s health care needs, a criterion for all breast/chest and genital surgeries is documentation of persistent gender dysphoria by a qualified mental health professional.’

What is ‘persistent gender dysphoria’?

A longstanding feeling that the gender a person was assigned at birth is different to the one that they identify with, and that those gender feelings cause significant discomfort together with the desire to take steps to change their body in order to alleviate this discomfort.

Who can assess for surgery?

According to WPATH, persistent gender dysphoria should be documented by a ‘qualified mental health professional.’

What is a ‘qualified mental health professional’?

WPATH – ‘Mental health professionals assess clients’ gender dysphoria in the context of an evaluation of their psychosocial adjustment (Bockting et al., 2006; Lev, 2004, 2009). The evaluation includes, at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender nonconformity on mental health, and the availability of support from family, friends, and peers (for example, in-person or online contact with other transsexual, transgender, or gender-nonconforming individuals or groups). The evaluation may result in no diagnosis, in a formal diagnosis related to gender dysphoria, and/or in other diagnoses that describe aspects of the client’s health and psychosocial adjustment. The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to, or better accounted for, by other diagnoses.’

‘Mental health professionals with the competencies described above (hereafter called “a qualified mental health professional”) are best prepared to conduct this assessment of gender dysphoria.’

Mental Health Professionals in the UK

Definitions may vary between the USA and the UK, but the important issue is that a qualified mental health care professional does not have to be a doctor or a psychiatrist.

There is a concise definition given by the Northern Ireland Government website, and the list includes:

  • social workers
  • community mental health nurses
  • occupational therapists
  • psychiatrists
  • psychologists
  • mental health pharmacists
  • counsellors
  • community support workers

How many referral letters do you need?

For breast enhancement in trans feminine people, or chest reconstruction in trans masculine people, one referral letter is required.

For genital gender-affirming surgery, two assessments and recommendations are required.

The WPATH criteria for qualifying for surgery are as follows:

Criteria for Breast/Chest Surgery (One Referral)

Criteria for mastectomy and creation of a male chest in FtM patients:

  1. Persistent, well-documented gender dysphoria;
  1. Capacity to make a fully informed decision and to consent for treatment;
  1. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
  1. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a prerequisite.

Criteria for breast augmentation (implants/lipofilling) in MtF patients:

  1. Persistent, well-documented gender dysphoria;
  1. Capacity to make a fully informed decision and to consent for treatment;
  1. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
  1. If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

Criteria for Genital Surgery (Two Referrals)

The criteria for genital surgery are specific to the type of surgery being requested.

Criteria for hysterectomy and salpingo-oophorectomy in FtM patients and for orchiectomy in MtF patients:

  1. Persistent, well-documented gender dysphoria;
  1. Capacity to make a fully informed decision and to consent for treatment;
  1. Age of majority in a given country;
  1. If significant medical or mental health concerns are present, they must be well controlled.
  1. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).

The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention. These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria.

Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients:

  1. Persistent, well-documented gender dysphoria;
  1. Capacity to make a fully informed decision and to consent for treatment;
  1. Age of majority in a given country;
  1. If significant medical or mental health concerns are present, they must be well controlled;
  1. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).
  1. 12 continuous months of living in a gender role that is congruent with their gender identity. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

 

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