Gender-Affirming Care: The Role of Letters of Readiness in Gender Affirmation Surgery

 

BY MICAH HOFFMAN, MD, DABPN, FAPA,

ALLMED BEHAVIORAL HEALTH MEDICAL DIRECTOR

Treating members with gender dysphoria calls for a carefully considered, multi-step process. Through such an approach, many transsexual, transgender, and gender non-conforming individuals find comfort with their gender identity without surgery. In recent decades, however, growing evidence has made it increasingly clear that for some individuals, relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity.¹ For these members, surgery is essential, and ensuring behavioral health stability is a critical prerequisite to maximize long-term well-being and satisfaction.

For guidance on when gender affirming surgery can be appropriately considered medically necessary, many clinicians and health plans rely on the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC). The WPATH recommendations are based on an expanding body of clinical evidence combined with expert consensus.

The WPATH standards consider accompaniment by a mental health professional to be essential in an individual’s gender journey. Treating potential coexisting mental health issues can provide significant relief and may influence the individual’s perspective on surgery. In all cases in which irreversible surgery is being considered, thorough evaluation by a qualified mental health professional is viewed as imperative.

The SOC stipulate that “genital and breast/chest surgeries as medically necessary treatments for gender dysphoria are to be undertaken only after assessment of the patient by qualified mental health professionals as outlined in section V11 of the SOC.²” The standards further emphasize that surgeries should be performed only once there is written documentation that the assessment has occurred, and that the individual has met the criteria for a specific surgical treatment.

Clear Communication on Critical Issues

Specifically, the WPATH SOC recommend one referral from a qualified mental health professional for breast/chest surgery and two referrals for genital surgery. To be considered qualified for the purpose of writing a letter of readiness, the mental health professional must hold at least a master’s degree.

The letters should include³:

1. The client’s general identifying characteristics;
2. Results of the client’s psychosocial assessment, including any diagnoses;
3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
5. A statement about the fact that informed consent has been obtained from the patient;
6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

The referral letters recommended by WPATH serve as vital evidence that surgical candidates have undergone a thorough psychological assessment and have met the criteria for the proposed surgery. In addition, the letters affirm that the individual will have long-term support from a qualified mental health professional as they continue through the process.

At AllMed, our multidisciplinary gender affirming care panel rigorously reviews members’ referrals to assess readiness and adherence to the WPATH SOC. With an awareness of current guidelines and relevant, up-to-date expertise, our board-certified specialists help your team make determinations of medical necessity with confidence and foster healthy, positive outcomes for members.

 

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