Surgical readiness referral

Access to different types of gender affirming surgery is contingent upon receiving one or two referrals (depending on the surgery) by a mental health professional. WPATH’s Standards of Care offer suggestions on the minimum competencies that a mental health professionals should have when working with trans patients seeking surgical affirmation.  

The Standards of Care also helpfully lists the professions endorsed as mental health professionals able to form part of a trans person’s multi-disciplinary support team (along with, for example – GP, surgeon, peer worker and allied health clinicians).  

For those seeking hormonal affirmation, gender affirming GPs are best placed to initiate and manage partial and total feminising and masculinising therapy regimens. A referral from a mental health professional is typically not necessary for the vast majority of trans patients – binary and non-binary. Find out more about hormone prescribing here. 

Competency of Mental Health Professionals

  1. Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
  2. For countries requiring a diagnosis for access to care, the health care professional should be competent using the latest edition of the World Health Organization’s International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilize the latest ICD as soon as practicable.
  3. Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
  4. Are able to assess capacity to consent for treatment.
  5. Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
  6. Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S32

Provided a patient is able to demonstrate capacity to make an informed decision, approval by a mental health professional is not required for adults in order to commence gender affirming hormone therapy.  

In addition to the above, the following are recommended minimum credentials for mental health professionals who assess, refer, and offer therapy to children and adolescents presenting with gender dysphoria:  

  1. Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
  2. Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
  3. Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
  4. Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S48

For patient considering affirming surgery, it can be helpful to refer to mental health professionals ahead of time. The WPATH’s Standards of Care 8 note that:

Counseling or psychotherapy can be helpful when requested by a TGD person. However, counseling or psychotherapy specifically focused on their TGD identity is not a requirement for the assessment or initiation of GAMSTs (gender-affirming medical and/or surgical treatments).

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S31

We have prepared a letter that outlines what is required in a surgical readiness referral, which you can find in the downloads section below.

Standards of Care (SoC8) 

The Standards of Care – 8th edition (SoC8) are published by the World Professional Association for Transgender Health (WPATH) and offer guidance to clinicians working with trans patients, including recommended referral pathways for those seeking particular medical and surgical interventions.  

The SoC8 do not specify an order by which surgeries should occur, and are guidelines, not legislated requirements. 

Recommendations regarding the requirements for gender-affirming medical and surgical treatment

  1. Only recommend gender-affirming medical treatment requested by a TGD person when the experience of gender incongruence is marked and sustained.
  2. Ensure fulfillment of diagnostic criteria prior to initiating gender-affirming treatments in regions where a diagnosis is necessary to access health care.
  3. Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments.
  4. Ensure that any mental health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.
  5. Ensure any physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.
  6. Assess the capacity to consent for the specific physical treatment prior to the initiation of this treatment.
  7. Assess the capacity of the gender diverse and transgender adult to understand the effect of gender-affirming treatment on reproduction and explore reproductive options with the individual prior to the initiation of gender-affirming treatment.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S32

While noting the importance of the ‘nature, length and consistency’ of gender incongruence, WPATH highlight the fact that gender incongruence ‘can exist in the absence of disclosure to others’. Another important thing they mention is that ‘while marked and sustained gender incongruence should be present, it is not necessary for TGD
people to experience severe levels of distress regarding their gender identity to access gender- affirming
treatments. In fact, access to gender-affirming treatment can act as a prophylactic measure to prevent
distress’.

They also recommend:

  • to consider the role of social transition together with the patient
  • that only a single opinion for the initiation of gender-affirming medical and treatment be required.
  • to inform transgender and gender diverse people undergoing gender-affirming surgical procedures about aftercare requirements, travel and accommodations, and the importance of postoperative follow-up during the preoperative process.

Additional fertility considerations

We recommend health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about:

  • Known effects of hormone therapies/surgery on future fertility;
  • Potential effects of therapies that are not well studied and are of unknown reversibility;
  • Fertility preservation (FP) options (both established and experimental);
  • Psychosocial implications of infertility

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S157

Additional criteria for chest surgeries (mastectomy & breast augmentation)

We recommend surgeons assess transgender and gender diverse people for risk factors associated with breast cancer prior to breast augmentation or mastectomy.

    Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S129

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

    Additional Criteria for Genital Surgery

    The criteria for genital surgery are specific to the type of surgery being requested. Criteria for hysterectomy and salpingo-oophorectomy in AFAB patients and for orchiectomy in AMAB patients: 

    1. We recommend surgeons confirm reproductive options have been discussed prior to gonadectomy in transgender and gender diverse people.
    2. We suggest surgeons consider offering gonadectomy to eligible* transgender and gender diverse adults when there is evidence they have tolerated a minimum of 6 months of hormone therapy (unless hormone replacement therapy or gonadal suppression is not clinically indicated or the procedure is inconsistent with the patient’s desires, goals, or expressions of individual gender identity).
    3. We suggest health care professionals consider gender-affirming genital procedures for eligible* transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).

    Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S129

    Additionally, for metoidioplasty/phalloplasty:

    We suggest surgeons caring for transgender men and gender diverse people who have undergone metoidioplasty/phalloplasty encourage lifelong urological follow-up.

    Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, p.S129

    Gender Incongruence – WHO ICD-11

    In 2019, the World Health Assembly of the World Health Organization (WHO) endorsed two new diagnostic codes: Gender Incongruence in Adults and Adolescents, and Gender Incongruence in Childhood, for the 11th edition of its International Classification of Diseases (ICD-11). 

    This endorsement takes the medicalisation of trans people out of the Mental Health chapter and into a newly established Sexual Health chapter, alongside other hormonal and urogenital related issues. 

    Part of this is a move away from requiring trans people to be experiencing distress or pain (ie. In the case of Gender Dysphoria), and a recognition that misery isn’t synonymous with being trans. In healthcare settings, treatment provided for distress is captured by the ICD-11 codes related to anxiety and depression, and not as an inherent part of trans experience. 

    This is part of the global shift in healthcare toward recognising that access to gender affirmation should be facilitated, and is medically necessary, for any person whose gender is different to what was presumed for them at birth. For those accessing surgery, this change encompasses the breadth of experience held by trans people wanting and requiring surgeries. 

    The WHO ICD-11 code is as follows:

    Gender Incongruence of Adolescence and Adulthood is characterized by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis. 

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