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The Informed Consent Model for Gender-Affirming Surgery

Informed consent is a particularly important process for transgender, non-binary and gender-non conforming people because it gives them autonomy over their own healthcare. Historically, the trans and gender non-conforming community has had a difficult time accessing quality, gender-affirming health care in part because of gatekeeping and discrimination on behalf of mental health providers and medical professionals. Therapist-mediated support and the therapeutic process can be highly valuable in the gender transition journey. The informed consent model honors patients’ self-knowledge and ability to make informed decisions regarding medical interventions they want to access. The GCC acknowledges that, regardless of insurance coverage requirements, adults who have the proper education are able to determine for themselves if they are ready and willing to access surgery. This extends to trans people who do not fall within the binary; patients of all genders are able to determine their own surgical goals in collaboration with their surgeon and other providers. Our practice’s exceptions to the use of the informed consent model are explained below.

Should I seek out a mental health professional before surgery?

While our practice does not require a letter from a therapist or mental health professional for adult patients under most circumstances, we recognize that therapists can be an invaluable source of support for patients undergoing a medical gender transition. When possible, we recommend that our patients seek out professional psychological support for their surgical journey when it is right for them. It is important to note that if you are pursuing insurance coverage of your surgery, you will need to get at least one support letter from a licensed mental health provider if your health insurance provider follows the WPATH Standards of Care (SOC-8) for coverage of surgery. While letters can be helpful at times to establish whether patients have proper support going into surgery, they can also be seen as a barrier to accessing surgery.

When are support letters required to get surgery?

The following documentation is required of legal adults in order to undergo surgery with the Gender Confirmation Center. Parents or guardians of adolescents interested in top surgery can reach out to our office with questions about the requirements for this population.

Patients who are interested in having their insurance cover their procedure(s): 

• First, a support letter from a mental health professional should be provided so that we can move forward with requesting coverage from your insurance. Second, if Gender Confirmation Center surgeons are not considered in-network providers by your insurance plan, you will need a referral letter from your primary care provider.
• Please note that if you are interested in bottom surgery, you will need to present two support letters. At least one should come from a licensed mental health professional. The second can come from a mental health or a healthcare provider: for example, an endocrinologist or primary care provider who has been involved in your hormone therapy.
• We recognize that the two-letter insurance requirement can be an extra barrier for patients to access medically necessary, gender-affirming care. For this reason, once you have requested a surgical consultation, we can help you through securing this and any other documentation.

‘Cash-pay’ patients who will be financing their surgery without insurance:

• Per the WPATH’s Soc 8 guidelines, patients interested in bottom surgery will need to present one support letter from a licensed mental health professional to be eligible for surgery. Dr. Ley does not require support letters for patients
• Dr. Ley does not require that patients present a support letter to undergo a bottom surgery revision procedure. Whether or not you underwent your initial bottom surgery procedure with her, the support letter eligibility requirement will be waived.

Are consultations free with the Gender Confirmation Center?

Yes! At the GCC, we do not charge patients for consultations, virtual or in-person, with our surgeons. We recognize that many trans, non-binary and gender non-conforming patients experience immense financial barriers to accessing medically necessary gender-affirming care. In addition to offering our consultations free of charge, we provide a free insurance concierge service that has successfully secured insurance coverage for over 90% of interested patients. To request a consultation today, click here.

Recently, our practice has experienced several last-minute cancellations and no-shows to consultations. This has a negative impact on our community’s ability to access medically necessary, gender-affirming care. To reduce last-minute cancellations, rescheduling and no shows, we will:

1. Require our Patient Care Coordinators (PCCs) to follow-up with patients more diligently to remind them of their consultation dates and times.
2. Implement a system to deprioritize the scheduling of prospective patients who have canceled, rescheduled or were a no-show for their consultations on multiple occasions.
3. PCCs will work closely with patients to help them complete all the required documentation before surgery. Candidates with completed documentation will be prioritized to schedule a consultation.

Knowing you’re ready for surgery

The decision to get surgery can feel like a big one, and it can be helpful to seek external support and resources for help if you need it. Seeking counseling with a therapist or other licensed mental health professional, or support through in person and online support groups to speak to others who have a similar experience, can be helpful to discern your own motivations and feelings regarding surgery. Having an established relationship with a mental health provider can be helpful if you need letters of support for surgery as well. Ultimately, the decision to get surgery should be self-directed and a result of your own needs and motivations, not through external pressures or expectations. Some people are able to make this decision rather quickly, and others need more time. However long it takes you, and whatever resources you need, it is okay as long as it is going at a pace that feels comfortable to you!