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Best Practices For Mental Health Providers in Providing Gender Affirming Assessments for Surgery Referral Letters

A new webinar from the Behavioral Health Department at Fenway Health provides guidance for mental health providers in providing gender affirming assessments for surgery referral letters for transgender and gender diverse people. The webinar, titled Providing Mental Health Assessments for Gender Affirming Surgery Referral Letters, is led by Fenway Health’s Sarah Eley, LICSW, Behavioral Health Specialist in Primary Care.

There is a history in the mental health and medical fields of pathologizing transgender, gender non-binary and gender diverse people. Despite political and social activism outside of and within these fields to remove Gender Dysphoria from the DSM (Diagnostic Statistical Manual V) it still exists, and because of this and the existing requirements by WPATH (World Professional Association for Transgender Health) Standards of Care (SOC), insurance companies and surgeon requirements for eligibility for receiving coverage and having gender affirming surgeries, gender diverse people are required to see 1-2 mental health providers for a mental health evaluation and letter of referral, in addition to getting a letter from their Primary Care Physicians.

The purpose of these assessment letters is to assess emotional stability and confirm these three primary categories: 1) Presence of persistent gender dysphoria (distress caused as a result of misalignment between someone’s internal gender identity and their sex and gender assigned at birth and/or distress caused as a result of experienced external and internal gender oppression; transphobia), 2) If any mental health issues are present, they are reasonably well controlled, and 3) someone has lived in their identified gender for at least one year. These requirements put out by WPATH SOC can vary based on surgeon and insurance requirements.

Beyond actually providing the evaluations and writing these referrals, Eley notes that it is critical for providers to be cognizant of the gatekeeping role they have been asked to assume in this process. Eley states that within an assessment process (which can range from 1-4 +/-sessions) the additional purpose is to support a person’s goals for surgery while affirming and respecting the client’s gender identity. Beyond providing the necessary paperwork for gender affirming surgery, providers are there to empathize with their clients’ choice to have surgery, help their clients navigate surgical logistics, understand procedures and potential risks, and plan next steps in leading up to and in recovery from these gender affirming surgeries.

This webinar explains how to structure gender affirming surgery assessments and referrals, outlining the categories of assessment information that needs to be included, as well as the different types of referrals that may be needed depending on the client’s wishes and any specific surgical or insurance requirements. It emphasizes the importance of providers educating themselves and not relying on their clients for information about gender and their health and wellness needs.

“Acknowledging the power dynamic in the room is important,” she stresses. For many transgender and non-binary clients, having to go through such evaluations and assessments in order to access gender affirming care can be painful or even traumatic.

“Providers may not entirely understand the impact gender dysphoria can have on somebody’s day to day experience navigating the world,” Eley said. “Receiving these gender affirming surgeries can really provide a huge amount of relief for transgender and non-binary people. If this assessment is a required process, then we as providers can also use this as a way to affirm and support people in their journey.”

Please click here to access this full webinar.

Fenway Health offers a number of support and therapy groups for transgender people, their loved ones and community. For a full listing of these groups, please click here.

The Transgender Health ECHO program at the National LGBT Health Education Center is an opportunity for your federally qualified community health center to learn from experts and apply those learnings to increase the availability of culturally responsible, comprehensive primary care for transgender people. To learn more and apply, please click here.


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