By Theo Schall


How many doctors should have to sign off before a transgender person is allowed to get sex reassignment surgery? A newly published paper calls into question the ethics of the current protocol, which requires that transgender people obtain two separate referrals from mental health professionals. Unfortunately, the paper also argues for a strengthened use of another requirement – the so-called “real life test” – that’s long been criticized as ethically unsound.


Sex reassignment surgery poses a challenging ethical question in that it requires the removal of healthy tissue, is generally irreversible, and can impact fertility. Clinicians who must abide by the principle of non-maleficence often find it challenging to conceive of such procedures as anything other than harmful. What if patients change their minds later and come to regret irreversible surgical procedures? What if complications arise and patients are “unnecessarily” harmed? How can doctors distinguish transgender patients from the small minority of patients suffering from other conditions that present as gender dysphoria?



It’s worth noting that not every gender dysphoric person considers themselves transgender and not all transgender people want surgical interventions. Yet, when sex reassignment surgery is appropriate, studies have found that it has positive outcomes and is almost always seen as a benefit by people who undergo it. Ameliorating gender dysphoria, the often acutely painful feeling of mismatch between the sex one is assigned at birth and one’s internal gender identity, can positively impact depression and suicidality. When treating transgender patients who need surgery, compassionate clinicians ought to consider not just non-maleficence, but also beneficence. Sex reassignment surgery may have the potential to harm patients, but it also has potential to do them significant good.


Clinicians who care for transgender people work in a marginal area of medicine. For example, there have been no clinical trials of transgender hormone use, so protocols vary by location and even clinic-to-clinic. Thus, oversight and interdisciplinary collaboration are vital to ensuring safe and standardized pathways to care. The most commonly used Standards of Care, produced by the World Professional Association of Transgender Health (WPATH), recommend requiring one written opinion from a qualified mental health professional before transgender people can begin hormone treatment or undergo chest surgeries. In contrast, two referrals from qualified mental health professionals are recommended for below-the-belt surgeries. While these recommendations aren’t mandates, clinicians who follow them are more protected from legal or professional censure than those who choose not to.


In their paper Yes and Yes Again: Are Standards of Care Which Require Two Referrals for Genital Reconstructive Surgery Ethical?, Bouman et al. question the value of the two-referral requirement. They argue that requiring two mental health referrals from all patients seeking sex reassignment surgery (rather than just those with complex or challenging diagnoses) is inappropriately burdensome and treats transgender patients unequally. Instead, the authors argue that the standard of care should be ongoing assessment and support from an interdisciplinary team – thereby eliminating the need for most patients to obtain multiple referrals. They appeal to WPATH’s advisory committee to consider their findings in the next revision of the Standards of Care.


There are a number of problems with these recommendations. Most obviously, the solution that Bouman et al. propose may be logistically impossible in many settings. The authors are a team from nations all over the world; it seems likely that many authors work in high-profile national gender identity clinics with diverse interdisciplinary staffs. Such clinics are rare. Many transgender patients live far from trans-competent clinicians, never mind specialist clinics, and may not have access to a team of caregivers.



A larger problem arises from the authors’ dependence upon the Standards of Care’s other recommendations. The Standards, which have been updated seven times since they were first drafted in 1979, remain controversial. This is especially true in the transgender community, which has pushed back against pervasive medical “gatekeeping.” Perhaps most contested is the Standards of Care’s “real life experience” requirement, in which a transgender person must live in the social role of their gender identity (e.g., female-identified transgender people live socially as women) for at least twelve months prior to accessing medical interventions.


Critics contend that the “real life experience” historically burdened transgender people with proving the legitimacy of their gender to psychiatrists, who were vested with the full power of medical paternalism and could refuse to help patients they thought would be ugly or atypical after treatment. Some transgender people are unable to live socially in their gender roles prior to medical intervention because other people continue to recognize them as their birth sex. This “real life experience,” which isn’t scientifically substantiated, has been called an “ethical vulnerability” of the Standards of Care.


In response to critics, the most recent revision eliminated the “real life” requirement – except in the case of genital surgeries. Despite the requirement’s diminishing use, Bouman et al. rely heavily on the presumed benefits of the “real life experience” as reason to offer less obstructed access to sex reassignment surgery. This argument against the two-referral requirement ultimately depends upon a requirement that is arguably even more problematic.


A number of American community health centers have opted to stop using the WPATH Standards of Care, choosing instead to provide services under an Informed Consent Model. The Informed Consent Model doesn’t require any mental health referrals at all. Clinicians must determine whether their patients have the capacity for informed consent, but they do not need to ask for proof in the form of mental health evaluations that a patient is a “true transsexual.” While this model clearly has risks as well as benefits for patients, it has gained popularity.


Nonetheless, it’s unlikely to replace the WPATH Standards of Care. As transgender people have gained social visibility, interest in providing insurance benefits to cover transgender health care has increased. Insurance companies and government payers, who tend to follow rigid textbook definitions, allow for less flexibility in diagnosis. The Informed Consent model, which skirts formal diagnosis entirely, will be largely incompatible with insurance coverage.


This puts real pressure on the Standards of Care, which are likelier than ever to be codified into contracts and policies. The critique of Bouman et al. is valuable inasmuch as it validates the rights of competent transgender patients to access care through ethically and scientifically sound processes. But invalidating the ethical basis of one obstacle by invocation of an equally questionable, substantially more burdensome one is a step in the wrong direction.

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Theo Schall

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One Response to “How Accessible Should Transgender Surgery Be?”

  1. Riley says:

    (A clearer version)Hi Theo! My name is Riley and I’m a 17 year-old trans boy. I’ve been recently rejected to receive any kinds of hormonal treatment and surgeries because my psychiatrist think I don’t have any real life experience as a boy. He stated that I don’t look like a typical boy enough. Here comes an important question: How do you define if a person is living as a life of the opposite sex? For example, if a trans girl wears pants and a trans boy has long hair, does it mean they are not livng as the opposite gender? The real life experience requirement is totally gender stereotypical and subjective! For me, no matter what I wear, I still live my life as a boy cuz what tells me I’m a boy comes from my brain. Nevertheless , without any hormonal treatment,how can I live a life as a male when all my physical characteristics are female? The “real life experience” is not REAL at all! I’m glad that there’s someone like you who shares the same view as I do and it’s a disgrace for the psychiatrists to think real life experience is the golden indicator to determine if a person is suitable for HRT amd GRS.

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