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

Abstract

Background:The World Professional Association for Transgender Health (WPATH) recommends referral letters from 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 requirements are not supported by WPATH guidelines.Objectives: This study investigates insurance requirements for referral letters and their negative impact on care. Materials and methods:We retrospectively reviewed all gGAS cases over 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, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed.Results: Nearly all reviewed U.S. health insurance plans required annually updated 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. Discussion and Conclusion: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 surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide 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 How to cite this article: Yuan N, Chung T, Ray EC, Sioni C, Jimenez-Eichelberger A, Garcia MM. Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

“…Consequently, if written documentation or a letter is required to recommend gender-affirming medical and surgical treatment (GAMST), TGD people seeking treatments including hormones, and genital, chest, facial and other gender-affirming surgeries require a single written opinion/signature from an HCP competent to independently assess and diagnose (Bouman et al., 2014 ; Yuan et al, 2021 ). Further written opinions/signatures may be requested where there is a specific clinical need.…”

Using the companionship model when writing referral letters for transgender and nonbinary adults.

“…Ashley (2019) asserts that the practice is dehumanizing, predicated upon the inherent implication that the medical profession does not trust TNB people to make their own medical decisions, suppresses the diversity of TNB people’s experiences, and is an unjustified double standard when compared to other forms of clinical care. In addition to these ethical considerations offered by Ashley (2019), Yuan et al (2021) also investigated how insurance companies’ referral letter requirements affect TNB patients. Their analysis of over 800 cases at a medical center where referral letters were required for transition-related medical care found that the referral letter process delayed treatment and that insurance companies required patients to follow procedures that went above and beyond what the SOC required.…”

“…With the SOC Version 8 removing the requirement for referral letters for some specific transition-related medical interventions (but not all), one tension we foresee is that it will take time for insurance companies and medical clinics/providers to adjust their practice of requiring letters. One clear example of this is that some insurance companies even today refer to and at times ask providers to speak to clients’ “real life experience” in their gender (a requirement that was eliminated in SOC Version 7 (Yuan et al, 2021). In addition to the time it takes for insurance companies and medical clinics/providers to update their policies and procedures following the release of the newest SOC Version 8, some may intentionally choose to continue the practice of requiring referral letters in order to minimize liability.…”

The growing and interdisciplinary field of transgender health

“…in the United States for referral letters for gender-affirming genital surgery can negatively impact care. 13 Both medical and surgical treatment options may adversely affect the reproductive potential of TGD people. Rodriguez-Wallberg et al…”

“…Yuan et al. describe how burdensome insurance company requirements in the United States for referral letters for gender‐affirming genital surgery can negatively impact care 13 …”