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).

Page 22 of the SoC 7 writes that that "Clinical training may occur within any discipline that prepares mental health professionals for clinical practice, such as psychology, psychiatry, social work, mental health counseling, marriage and family therapy, nursing, or family medicine with specific training in behavioral health and counseling."

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. A master’s degree or its equivalent in a clinical behavioural science field. This degree, or a more advanced one, should be granted by an institution accredited by the appropriate national or regional accrediting board. The mental health professional should have documented credentials from a relevant licensing board or equivalent for that country

  2. Competence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Diseases for diagnostic purposes

  3. Ability to recognise and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria

  4. Documented supervised training and competence in psychotherapy or counselling

  5. Knowledgeable about gender-nonconforming identities and expressions, and the assessment and treatment of gender dysphoria

  6. Continuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.

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.

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. Meet the competency requirements for mental health professionals working with adults, as outlined above;

  2. Trained in childhood and adolescent developmental psychopathology; and

  3. Competent in diagnosing and treating the ordinary problems of children and adolescents.

For patient considering affirming surgery, it can be helpful to refer to mental health professionals ahead of time.

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 (SoC)

The current SoC (7th ed) for the Health of Transsexual, Transgender, and Gender Nonconforming People, published by the World Professional Association for Transgender Health offers guidance to clinicians working with trans patients, including recommended referral pathways for those seeking particular medical and surgical interventions.

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

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

Hormone therapy is not a prerequisite.

WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People V7

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

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (if younger, follow the SOC for children and adolescents);
  4. 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.

WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People V7

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;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country;
  4. If significant medical or mental health concerns are present, they must be well controlled.
  5. 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.

WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People V7

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

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country;
  4. If significant medical or mental health concerns are present, they must be well controlled;
  5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).
  6. 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.

WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People V7

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.

HA60 Gender incongruence of adolescence or adulthood - WHO ICD-11