Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

Abstract

The World Professional Association for Transgender Health (WPATH) recommends referral lettersfrom two mental health providers within one year of gender-affirming genital surgery(gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirementsare not supported by WPATH guidelines. This study investigates insurancerequirements forreferral letters and their negative impact on care. We retrospectively reviewedallgGAScasesover a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented.The nation's largest insurance companies, including commercial, state-, and federally funded plans, werecontacted to confirm requirements.We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATHpublicationswere reviewed. Nearly all reviewed U.S. health insurance plans requiredannuallyupdated referral letters for each gGAS procedure, including staged and revision surgeries.No updated letters changed clinical management.Referral letter requirements delayed care.WPATH states that letters should not be needed for staged surgeries.Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines.We advocate that, at minimum,referral letters should not be required for surgical consultations or for staged or revision surgeriesafter a patient has already had first-stage primarygGAS. Universalreferral letterrequirementsprovide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition.As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness.Significant changes in mental health status or social situation should prompt surgeons to seek reassessment.WPATH recommendationsregardingreferral lettersshould be clarified and consolidated into a single document.