Stop Burdening Transgender Patients With Paperwork, Surgeons Say

— Insurers often insist on multiple "referral letters" after primary procedures


SCOTTSDALE, Ariz. -- Surgeons are urging insurance companies to stop requiring transgender patients to get "referral letters" from mental-health professionals before they can undergo secondary and follow-up gender-reassignment operations or, in some cases, even get initial surgical consultations.

While they can be reasonable requirements before primary surgery, referral letters are "very pathologizing and insulting to a lot of patients" when required for further stages of surgery such as revision operations, said urologist , who performs transgender surgeries at Cedars-Sinai Medical Center in Los Angeles, speaking here at the annual scientific meeting of the Sexual Medicine Society of North America.

Garcia and colleagues previously reported on referral letter policies and called for reform in the journal .

"It's one thing to be reviewed once. It's another to be reviewed every single time," he told app. "I had a transgender woman patient who had surgery 20 years ago and needs a surgeon to do some revision surgery. She asked: 'Do we really need to put together a committee to say I'm of sound mind, and I've been living as a transgender person?'"

from the World Professional Association for Transgender Health (WPATH), which are generally followed by insurers, recommend that patients be required to get referral letters from two mental-health providers within a year before they undergo genital surgery. One letter is required for chest/breast surgeries such as mastectomies.

In the letters, mental-health professionals are expected to confirm that potential patients have met criteria for the operations. "They're intended as a safety measure to make sure that the patient is ready, and that we're not stepping into something unexpected," Garcia said.

He estimated that only two or three in 100 patients actually turn out to not be ready for the operations. "Some are homeless or have a drug abuse problem that can really sabotage the outcome of a surgery," he said.

According to Garcia and colleagues, the problem is that insurers often require pairs of letters for non-primary surgeries such as follow-up procedures to repair problems. They're also often required for the second and third stages of genital operations such as phalloplasties.

The letters simply aren't necessary, Garcia said. "A revision surgery to fix a urethra after a vaginoplasty has nothing to do with sexuality or gender dysphoria. It's just a urinary problem that needs fixing."

To make the situation more difficult for transgender patients, it can be hard to find mental-health professionals -- and pay them -- to write the letters if the originals are out of date. "It's very disruptive to people, and it's degrading," Garcia said.

Garcia's team found almost all of the nation's 10 top insurance companies require referral letters for these procedures. Kaiser Permanente requires referral letters prior to initial surgical consultations, a policy that Garcia's team opposes. Medicare's policy is murky, the team reported: "clarification could not be obtained despite multiple phone calls to Medicare representatives."

The researchers also noted that two insurers -- United Healthcare and Aetna -- said they didn't require referral letters in certain surgeries, but these policies weren't followed in practice: "Our staff were routinely asked for updated referral letters in all cases of revision and staged surgeries, with authorizations denied until referral letters were provided."

According to Garcia, insurers have required them because of confusion about the WPATH guidelines. "It was never just bad policy," Garcia said. "There were just bad policy interpretations."

There's no sign of organized support in favor of the requirement for the referral letters after primary surgery. When reached by app, WPATH Executive Director Blaine Vella said the next version of the organization's guidelines is expected to address concerns about referral letters requirements. The updated guidelines are expected to be released by December 31, she said.

For now, Garcia said, "physicians should cite our paper and push back" against unnecessary referral letter requirements. "It's not right or fair to ask patients to do something so costly for no good reason."

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    Randy Dotinga is a freelance medical and science journalist based in San Diego.


A research grant from Richard Onofrio, MD, funded the statement. Garcia and the other study authors report no disclosures.

Primary Source

Sexual Medicine Society of North America

Yuan N, et al "Requirement of mental-health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care" SMSNA 2021; Abstract 155.

Secondary Source


Yuan N, et al "Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care" Andrology 2021; DOI: 10.1111/andr.13028.