TLDR: Join me in urging the California State Legislature in creating and passing a bill to require informed consent from transgender patients seeking gender affirming surgeries rather than the mental health assessments currently required.

Currently trans individuals are required to obtain a letter assessment from a mental health practitioner before they are permitted to obtain gender-affirming surgeries (at least one letter for top surgeries and two letters for bottom surgeries). The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) version 7 for mental health practitioners working with trans and non-binary people indicates that the mental health practitioner is responsible for providing “documentation—in the chart and/or referral letter—of the patient’s personal and treatment history, progress, and eligibility” for gender-affirming surgery. This places the mental health practitioner in the role of gatekeeper deciding who is and who is not eligible for this care. The WPATH SOC v7 goes on to say “A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy—although highly recommended—is not a requirement." Despite this guideline indicating that therapy is not required, many practitioners require a certain number of sessions with a client before they will write the referral for surgery adding yet another barrier for trans people to accessing care. 

A 2020 study done on the experiences of trans people seeking letter assessments for gender-affirming surgeries noted that “participants felt that their autonomy and competency to make their own decisions were invalidated and disrespected” in the process and that the letter requirement “contributed to systemic barriers to transition, including difficulty accessing affirming therapists." The study also noted the participants’ frustration over the “time, energy, and financial resources” that the letter requirement demands.

Cisgender patients going in for the same genital and breast/chest surgeries are able to do so without a mental health assessment. In such cases, surgeons rely on an informed consent model in which the surgeon explains the risks and the benefits of the surgery to the patient and the patient makes their decision regarding the surgery and what they know is best for themself. The informed consent model alleviates barriers to accessing treatment, like the gatekeeping requirement of a mental health assessment, and does so without relying on the pathologizing narratives required with the current model. With informed consent, therapy is an option rather than a requirement or prerequisite. The decision regarding whether or not a mental health assessment should be required to obtain these surgeries should not be a rule applied to all trans people but rather only to those who do not have the capacity to provide informed consent.

Mount Sinai conducted a study comparing the patient-centered approach in assisting patients with recovery for complicated non-gender-related surgeries with the approach outlined in WPATH’s Standards of Care and noted that utilizing the WPATH’s approach, which has been widely accepted worldwide, “create[s] a barrier to care… and miss[es] the opportunity to identify critically important psychosocial factors such as adequate housing and social support necessary for successful recovery."

Extending this informed consent, patient-centered model to gender-affirming surgeries for trans people provides them the autonomy to make the decisions that are right for them without needing a mental health professional’s blessing. This would be truly gender-affirming. In a time in this country where trans rights are being attacked, moving away from the WPATH SOC and toward an informed consent model would show trans people all over the United States that California is gender-affirming and cares about trans people’s right to autonomy. 

For these reasons, I hope that the California Legislative LGBTQ Caucus will create a bill requiring surgeons, insurance companies, and government payers in California to accept the informed consent model for gender-affirming surgeries and eliminate the barriers caused by the current letter assessment requirements. Creating such a bill can change the relationship between trans people and the healthcare system, giving them faith that their gender will be affirmed and that their experiences are trusted, believed, and honored. Making this change to an informed-consent model is congruent with social work values, especially the principle of honoring the dignity and worth of the person through promoting “clients’ socially responsible self-determination." It will also show trans people that they belong, that their gender dysphoria is a medical condition not a mental condition, and that California trusts them to be able to make healthcare choices for themselves in the same ways that we trust cisgender people to make healthcare decisions for themselves. 

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