Editing Gender-affirming surgery (section)

== Prior to surgery ==

=== Medical considerations ===
Some medical conditions, including [[diabetes]], [[asthma]], and HIV, can lead to complications with future therapy and pharmacological management.<ref>{{cite journal | vauthors = Bishop BM | title = Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review | journal = Pharmacotherapy | volume = 35 | issue = 12 | pages = 1130–1139 | date = December 2015 | pmid = 26684553 | doi = 10.1002/phar.1668 | s2cid = 37001563 }}</ref> Typical gender-affirming surgery procedures involve complex medication regimens, including [[sex-hormone therapy]], throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including [[Endocrinology|endocrinologists]], whom the surgeon may consult when determining if the patient is physically fit for surgery.<ref name="Hage_1995">{{cite journal | vauthors = Hage JJ | title = Medical requirements and consequences of sex reassignment surgery | journal = Medicine, Science, and the Law | volume = 35 | issue = 1 | pages = 17–24 | date = January 1995 | pmid = 7877467 | doi = 10.1177/002580249503500105 | s2cid = 22752221 }}</ref><ref>{{cite journal | vauthors = Bizic MR, Jeftovic M, Pusica S, Stojanovic B, Duisin D, Vujovic S, Rakic V, Djordjevic ML | title = Gender Dysphoria: Bioethical Aspects of Medical Treatment | journal = BioMed Research International | volume = 2018 | pages = 9652305 | date = 13 June 2018 | pmid = 30009180 | pmc = 6020665 | doi = 10.1155/2018/9652305 | doi-access = free }}</ref> Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.<ref>{{cite journal | vauthors = Redfern JS, Jann MW | title = The Evolving Role of Pharmacists in Transgender Health Care | journal = Transgender Health | volume = 4 | issue = 1 | pages = 118–130 | date = April 2019 | pmid = 31289749 | pmc = 6608700 | doi = 10.1089/trgh.2018.0038 }}</ref>

People with HIV or [[hepatitis C]] may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.<ref>{{Cite web |title=Standards of Care | work = WPATH World Professional Association for Transgender Health |url=https://www.wpath.org/publications/soc |url-status=live |archive-url=https://web.archive.org/web/20150814230505/http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%2C%20V7%20Full%20Book.pdf |archive-date=14 August 2015 |access-date=23 May 2021 }}</ref>

Fertility is also a factor considered in gender-affirming surgery, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.<ref name="Hage_1995" />

=== Gender dysphoric children ===
Gender-affirming surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it.<ref>{{cite journal | vauthors = Rafferty J | title = Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents | journal = Pediatrics | volume = 142 | issue = 4 | pages = e20182162 | date = October 2018 | pmid = 30224363 | doi = 10.1542/peds.2018-2162 | url = https://pediatrics.aappublications.org/content/142/4/e20182162 | url-status = live | access-date = 23 July 2021 | s2cid = 52288840 | doi-access = free | archive-url = https://web.archive.org/web/20190719160901/https://pediatrics.aappublications.org/content/142/4/e20182162 | archive-date = 19 July 2019 }}</ref> Preferred treatments for children include [[puberty blockers]], which are thought to have some reversible physical changes,<ref>{{Cite web |date=3 October 2018 |title=Gender dysphoria treatment |url=https://www.nhs.uk/conditions/gender-dysphoria/treatment/ |url-status=live |archive-url=https://web.archive.org/web/20131102135038/http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Treatment.aspx |archive-date=2 November 2013 |access-date=27 August 2021 | location = U.K. | work = National Health Service}}</ref> and sex hormones, which reduce the need for future surgery. Medical protocols typically require long-term mental health counseling to verify persistent and genuine [[gender dysphoria]] before any intervention, and consent of a parent or guardian or court order is legally required in most jurisdictions.{{citation needed|date=February 2022}}

=== Intersex children and cases of trauma ===
{{main|Sex assignment#Assignment in cases of infants with intersex traits, or cases of trauma}}

Infants born with intersex conditions might undergo interventions at or close to birth.<ref name="Bradley_1998">{{cite journal | vauthors = Bradley SJ, Oliver GD, Chernick AB, Zucker KJ | title = Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood | journal = Pediatrics | volume = 102 | issue = 1 | pages = e9 | date = July 1998 | pmid = 9651461 | doi = 10.1542/peds.102.1.e9 | s2cid = 7364636 | doi-access =  }}</ref> This is controversial because of the [[Intersex human rights|human rights]] implications.<ref name="un-fact">{{Cite conference |last1=United Nations |last2=Office of the High Commissioner for Human Rights |date=2015 |title=Free & Equal Campaign Fact Sheet: Intersex |url=https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |archive-url=https://web.archive.org/web/20160304071043/https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |archive-date=4 March 2016 |access-date=14 March 2016 |url-status=live}}</ref><ref name="coe">{{Citation |last1=Council of Europe |title=Human rights and intersex people, Issue Paper |date=April 2015 |url=https://rm.coe.int/16806da5d4 |archive-url=https://web.archive.org/web/20220121014309/https://rm.coe.int/16806da5d4 |access-date=23 May 2021 |archive-date=21 January 2022 |last2=Commissioner for Human Rights |author-link=Council of Europe |url-status=live}}</ref>

There can be negative outcomes (including [[PTSD]] and suicide) when the surgically assigned gender does not match the person's gender identity, which will be realized by the person only later in life.<ref>{{Cite book | vauthors = Boyle GJ |title=Transgenders and Intersexuals |publisher=Fast Lane (imprint of East Street Publications |year=2005 |isbn=978-0-9751145-4-4 | veditors = May L |location=Bowden, South Australia |pages=95–100 |chapter=The scandal of genital mutilation surgery on infants}}</ref><ref>{{Cite book | vauthors = Colapinto J |title=As Nature Made Him: The Boy Who Was Raised as a Girl |title-link=As Nature Made Him: The Boy Who Was Raised as a Girl |publisher=Harper Collins Publishers |year=2002 |isbn=978-0-7322-7433-7 |location=Sydney |author-link=John Colapinto}}</ref><ref name="si">{{Cite web | vauthors = Diamond M |date=6 November 2009 |title=Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up |url=http://www.hawaii.edu/PCSS/biblio/articles/1961to1999/1982-sexual-identity.html |url-status=live |archive-url=https://web.archive.org/web/20190830075115/http://www.hawaii.edu/PCSS/biblio/articles/1961to1999/1982-sexual-identity.html |archive-date=30 August 2019 |access-date=1 August 2011 | work = University of Hawaiʻi }}</ref>{{Cn|date=November 2022}} [[Milton Diamond]] at the [[John A. Burns School of Medicine]], [[University of Hawaii]] recommended that physicians not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a [[Disorders of sex development|disorder]].<ref name="moi">{{cite journal | vauthors = Diamond M, Sigmundson HK | title = Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia | journal = Archives of Pediatrics & Adolescent Medicine | volume = 151 | issue = 10 | pages = 1046–1050 | date = October 1997 | pmid = 9343018 | doi = 10.1001/archpedi.1997.02170470080015 }}</ref><ref>{{cite journal | vauthors = Diamond M, Beh HG | title = Changes in the management of children with intersex conditions | journal = Nature Clinical Practice. Endocrinology & Metabolism | volume = 4 | issue = 1 | pages = 4–5 | date = January 2008 | pmid = 17984980 | doi = 10.1038/ncpendmet0694 | hdl-access = free | s2cid = 13382948 | hdl = 10125/66380 }}</ref>

=== Standards of care ===
{{See also|Transgender rights}}

Gender-affirming surgery can be hard to obtain due to financial barriers, insurance coverage, and lack of providers. A growing number of surgeons are now training to perform such surgeries. In many regions, a person's pursuit of gender-affirming surgery is often governed, or at least guided, by documents called [[Standards of Care for the Health of Transgender and Gender Diverse People]] (SOC). The most widespread SOC in this field is published and often revised by the [[World Professional Association for Transgender Health]] (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the US and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of [[psychological evaluation]] and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly called the real life test [RLT]) before sex reassignment surgeries are covered by insurance.{{Citation needed|date=March 2019}}

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.{{Citation needed|date=March 2019}}

Many surgeons require two letters of recommendation for gender-affirming surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as [[gender dysphoria]]), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.<ref>{{Cite web | vauthors = Weber-Main AM |date=July 2012 | veditors = Fall H |title=Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (Version 7) |url=http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf |archive-url=https://web.archive.org/web/20120920085610/http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf |archive-date=20 September 2012 |access-date=31 October 2013 |website=wpath.org |publisher=[[World Professional Association for Transgender Health]]}}</ref><ref>{{Cite web |date=17 December 2003 |title=WPATH Standards of Care |url=http://www.tssurgeryguide.com/WPATH-standards-of-care.html |archive-url=https://web.archive.org/web/20140901020629/http://www.tssurgeryguide.com/WPATH-standards-of-care.html |archive-date=1 September 2014 |access-date=11 August 2014 |publisher=Tssurgeryguide.com}}</ref>{{update inline|date=December 2022}}<!--Previous text apparently relies on SOC7 not SOC8; the latter specifies that one 1 letter is needed if written documentation is needed at all.-->

Many medical professionals and many professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents.<ref name="WPATH Clarification" /><ref name="APA Policy Statement">{{Cite web |title=APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination |url=http://www.apa.org/pi/lgbc/policy/transgender.pdf |archive-url=https://web.archive.org/web/20090211231509/http://www.apa.org/pi/lgbc/policy/transgender.pdf |archive-date=11 February 2009}}</ref><ref name="NASW Policy Statment">{{Cite web |date=August 2008 |title=NASW Policy Statement on Transgender and Gender Identity Issues |url=https://www.socialworkers.org/assets/secured/documents/da/da2008/reffered/Transgender.pdf | work = National Association of Social Workers (NASW) |orig-date=2006 |access-date=2 September 2022 |archive-date=15 March 2023 |archive-url=https://web.archive.org/web/20230315223712/https://www.socialworkers.org/assets/secured/documents/da/da2008/reffered/Transgender.pdf }}</ref> However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.<ref>{{Cite web | vauthors = Wareham J |title=New Report Shows Where It's Illegal To Be Transgender In 2020 |url=https://www.forbes.com/sites/jamiewareham/2020/09/30/this-is-where-its-illegal-to-be-transgender-in-2020/ |url-status=live |archive-url=https://web.archive.org/web/20210430203254/https://www.forbes.com/sites/jamiewareham/2020/09/30/this-is-where-its-illegal-to-be-transgender-in-2020/ |archive-date=30 April 2021 |access-date=8 June 2021 | work = Forbes |language=en}}</ref>

=== Insurance ===
{{Globalize|section|United States|date=October 2019}}
A growing number of public and commercial health insurance plans in the US now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and [[hysterectomy]] (FTM).<ref name="hrc.org">{{Cite web |date=26 February 2009 |title=Health Insurance Discrimination for Transgender People |url=http://www.hrc.org/issues/transgender/9568.htm |archive-url=https://web.archive.org/web/20090226224337/http://www.hrc.org/issues/transgender/9568.htm |archive-date=26 February 2009 | work = Human Rights Campaign }}</ref> For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:
* a written initial assessment by a qualified licensed mental health professional
* persistent, well-documented gender dysphoria
* months of prior physician-supervised hormone therapy

In June 2008, the [[American Medical Association]] (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician."<ref name="ama-assn.org">{{Citation |title=AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients" |url=http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf |archive-url=https://web.archive.org/web/20090327094235/http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf |archive-date=27 March 2009}}</ref> Other organizations have issued similar statements, including WPATH,<ref name="WPATH Clarification" /> the [[American Psychological Association]],<ref name="APA Policy Statement" /> and the [[National Association of Social Workers]].<ref name="NASW Policy Statment" />

In 2017, the United States [[Defense Health Agency]] for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who is a trans woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since US military hospitals lack the requisite surgical expertise.<ref name="FirstMilitarySRS">{{Cite web | vauthors = Kube C |date=14 November 2017 |title=Pentagon to pay for surgery for transgender soldier |url=https://www.nbcnews.com/news/us-news/pentagon-oks-surgery-transgender-soldier-military-hospital-n820721 |url-status=live |archive-url=https://web.archive.org/web/20200730233535/https://www.nbcnews.com/news/us-news/pentagon-oks-surgery-transgender-soldier-military-hospital-n820721 |archive-date=30 July 2020 |access-date=15 November 2017 | work = NBC News}}</ref>