Transgender People Face Outsized Barriers to Genital Surgery

People who want genital reconstructions as part of their transition are asked for not one, but two mental-health referrals. Doctors are now questioning whether that requirement is ethical.

Not all transgender people want surgery, nor should surgery be held up as the gold standard for someone to completely transition to their gender identity. But for those who do want to go through with procedures to alter their genitalia, they must first jump through hoops that some doctors and advocates have argued recently are unethical.

The World Professional Association for Transgender Health (WPATH) has now published seven iterations of its guidelines for doctors who treat transgender people. The guide outlines the steps health professionals should take to ensure that a patient is treated well, and cared for appropriately. The report covers all kinds of things, from hormone treatments to voice and communication therapy, but a recent study singled out one particular recommendation: Right now, WPATH suggests that any individual seeking genital reconstructive surgery should be asked for two mental-health referrals before going through with the procedure.

The referrals are both required to list things like the patient's diagnosis, their identifying characteristics, their consent, and a rationale for the surgery. For context, trans patients who want elective chest surgery, such as mastectomies or breast augmentation, are required to get just one mental-health referral.

For further context, the new study notes that outside transgender healthcare there are very few procedures that require two health referrals, and theyre extreme cases, things like partial lobotomies for those with severe OCD or depression and electroconvulsive treatment for acute psychiatric illness. And non-trans patients who want access to genital surgery arent asked for any mental-health referrals for procedures. A non-trans man who suffers from chronic pain of the scrotum, for example, can elect to have an orchidectomya procedure to remove both testicleswithout a mental-health referral. Nor would a non-trans woman seeking a hysterectomy be asked to see two mental-health professionals. Likewise, there is no mental-health requirement for cosmetic surgeries like breast augmentation or rhinoplasty for non-transgender people, according to the American Society for Aesthetic Plastic Surgery.

In light of all this, the recent paper, published in Sexual and Relationship Therapy, calls into question the two-signature suggestion. The paper, titled Yes and yes again: are standards of care which require two referrals for genital reconstructive surgery ethical? goes through the reasons why doctors might have asked for two referrals, and ultimately concludes that two signatures are both unnecessary and unethical. Applying the two written qualified mental-health professionals opinion rule to all trans people, rather than those for whom it is clinically indicated, appears to be disproportionately prejudicial where the impact is delay, obstruction, and differential treatment, they write.

WPATH should change their recommendations, lead author Walter Pierre Bouman, a psychiatrist and the director of the Nottingham National Centre for Gender Dysphoria told me in an email, which are based on consensus rather than on evidence-based medicine.

There are a lot of reasons why asking for two signatures might be reasonable. These surgeries are irreversible and involve removing healthy tissue, so performing them on someone who might be suffering from psychiatric complications, or who might come to regret it, would certainly be bad. And not all doctors are actually qualified to perform genital reconstruction, and might take advantage of peopleputting barriers between patients and bad doctors can be a good thing. (At least one such case does exist. Dr. Russel Reid, a physician working in the U.K., pushed several patients towards surgery and was later found guilty of medical misconduct in a case that was controversial in the transgender community.)

On the flip side, recent research has shown that trans people are no more likely to suffer from mental illness than cisgender people are. And the rate of regret among trans patients who undergo surgery is extremely lowsomething like two or three percent. In fact, most studies suggest that gender-confirming surgeries vastly improve the quality of life of individuals who choose to go through with them. And the fact that the same surgery applied to a different personas in the case of the above orchidectomy examplechanges the requirements, suggests that something unequal is going on. From an ethical standpoint we really need to think about this in a way thats ethical across all populations, and thats not how things are right now, said Kristen Eckstrand, the co-director of the Program for LGBTI Health at Vanderbuilt University.

Eckstrand also points out that asking for more medical intervention is particularly difficult for transgender people, who are far more likely to face discrimination and stigma in the doctors office. Studies show that transgender people are less likely to seek out healthcare, and when they do, often face doctors who dont know what they need. We know that a good portion of transgender people who do access medical care end up teaching their provider about their needs and bodies, she said. The medical environment is tough for anyone but its particularly tough for transgender people.

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Transgender People Face Outsized Barriers to Genital Surgery