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We must replace psychiatric gatekeeping with informed consent for gender-affirming surgery

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A Viewpoint published in JAMA Surgery asserts that requiring gender-affirming surgical adult patients to obtain an assessment letter prior to surgery is an unnecessary barrier to care and that moving toward an informed consent model, which is in place for nearly all other surgical procedures, would benefit such patients. The prior standard requiring assessment of suitability for surgery by a mental health care professional was designed to prevent regret about undergoing surgical procedures. In practice, patient regret for gender-affirming surgical procedures is very rare, and there is no evidence that presurgical mental health screening reduces rates of regret.

The requirement for presurgical assessment for patients seeking gender-affirming surgery differs markedly from the informed consent model that is used for nearly all other surgical procedures. With informed consent, surgeons talk with patients about their goals for surgery as well as the benefits and risks of surgery.

“Cisgender adults routinely undergo hysterectomies, breast augmentation or reduction, and rhinoplasty without a requirement for separate assessment by a mental health clinician,” said senior author Dr. Alex S. Keuroghlian, who directs the National LGBTQIA+ Health Education Center at The Fenway Institute and the Massachusetts General Hospital Psychiatry Gender Identity Program. “Rather than keeping these disparities between cisgender and transgender patients in place, we should trust transgender people to know their own identities and health care priorities in the same way we trust cisgender people.”

Transgender adults seeking gender-affirming surgery have typically already engaged in other forms of affirmation, such as changing name and gender markers on government-issued forms of identification, chest binding, genital tucking or packing, and gender-affirming hormone therapy.

“There is a growing body of evidence showing that people who desire gender-affirming care but are not able to access it experience psychological distress,” said Dr. Keuroghlian. “Moving toward a model of informed consent for gender-affirming surgery will increase access to this medically necessary care, while also minimizing the harm caused by psychiatric gatekeeping.”

The Viewpoint offered five recommendations for taking an informed consent approach to gender-affirming surgery:

  • Surgeons should assess a patient’s suitability for surgery by obtaining a gender history, evaluating the patient’s goals and expectations for surgery, and determining the patient’s capacity to consent to surgery. This assessment should be performed in conjunction with other presurgical assessments for medical readiness.
  • Surgeons should obtain informed consent by discussing the process and likely results, benefits and risks of surgery with patients.
  • If there is concern that uncontrolled mental health problems in patients may interfere with a patient’s capacity to consent to surgery, the surgeon should require evaluation by a mental health provider prior to surgery.
  • Surgeons should receive standardized and robust training in gender-affirming care.
  • More centers of excellence in gender-affirming surgery are needed in geographically diverse regions, with integrated access to mental health professionals who can support transgender patients and surgical teams as needed throughout the gender-affirming surgery process.

“Moving Beyond Psychiatric Gatekeeping for Gender-Affirming Surgery,” was published online by JAMA Surgery on December 14, 2022. It is available here.

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