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Understanding the WPATH Standards of Care Requirements for Gender-Affirming Surgery

Understanding the SOC surgery requirements helps patients clarify the steps needed to qualify for gender-affirming surgery, navigate insurance coverage, and assess their own readiness for surgery, ultimately enhancing satisfaction with the process.

The SOC outline specific requirements for gender-affirming surgeries, ensuring that the procedure is medically necessary and that patients receive appropriate care.

Note: Not all surgeons follow the SOC requirements. For instance, some Top Surgery and facial surgeons may not require a letter from a mental health provider, as long as the patient fully understands the benefits and limitations of the surgery and is paying out-of-pocket.

Public health insurance and private insurers, however, typically adhere to the SOC guidelines for surgery, sometimes with additional requirements. As a result, patients using insurance to pay for surgery must meet both the SOC requirements and any additional conditions set by their insurance provider.

The general requirements for gender-affirming surgery according to the SOC:

1. Gender Dysphoria Persistent, well-documented gender dysphoria is a primary requirement to qualify for surgery. This diagnosis must be made by a mental health professional (e.g., a licensed therapist or psychologist) who has experience with gender identity and gender-related care. The diagnosis must confirm that the individual experiences significant distress due to the incongruence between their gender identity and their assigned sex at birth.

2. Informed Consent The patient must provide informed consent for the surgery. This includes understanding the potential risks, benefits, and limitations of the procedure, as well as the possible impact on physical and emotional well-being. Patients must also be informed about post-surgical care and recovery expectations.

3. Psychosocial Assessment A psychosocial evaluation by a licensed mental health professional is usually required to assess the patient’s readiness for surgery. This assessment may include:

• Exploring the patient’s gender identity and personal readiness for surgery.
• Assessing the patient’s mental health history and ensuring they are stable enough for surgery (e.g., absence of severe untreated mental health conditions).
• Confirming that the patient has adequate support systems and coping mechanisms in place for post-surgical recovery.

The mental health provider also writes a surgical readiness letter , also referred to as a letter of medical necessity, which recommends surgery for the patient and confirms that they meet the surgical requirements.

4. Living in the Desired Gender Role The SOC typically recommend that the patient has lived in their desired gender role for a certain period, often at least 12 months, prior to surgery. This is sometimes referred to as the “real-life experience” or “social transition.” This requirement may vary depending on the patient’s unique circumstances, provider, and insurance policies. This step demonstrates the patient’s commitment to transitioning and their ability to manage the practical and emotional aspects of gender transition.

5. Age Requirement The latest version of the SOC makes no recommendations on specific ages for any treatment, including surgery. The SOC generally recommend that patients be at least 18 years old to undergo gender-affirming surgery, although exceptions may be made in certain cases for minors, depending on legal and medical guidelines in the jurisdiction and the patient’s situation. For example, some surgeons will perform Top Surgery on a minor, just as other breast procedures are offered to cis gender minors, but only with parental consent and a recommendation for surgery from two qualified mental health providers.

It is extremely rare for patients under 18 to receive genital surgery. Even if a minor meets other criteria for surgery, the surgeon, medical facility, and/or insurance company will almost certainly require the patient to be the age of majority to undergo irreversible genital surgery.

NOTE: TransHealthCare requires users to be age 18 or over to use the consult/info request feature of the website.

6. Stable Mental Health Patients should have stable mental health before undergoing surgery. This means that individuals should not be experiencing untreated mental health conditions that could impair their ability to make decisions about surgery or negatively affect their recovery. If the individual is experiencing mental health issues such as depression or anxiety, they may be required to address these conditions first with therapy or treatment before moving forward with surgery.

7. Hormone Therapy While hormone therapy is often recommended before surgery, it is not always a strict requirement under the SOC. Some individuals may be eligible for surgery even if they have not undergone hormone therapy, particularly if they are not seeking hormone treatment or are medically contraindicated from taking hormones. The decision is often made on a case-by-case basis with input from the healthcare provider.

However, an important exception applies to Metoidioplasty , a gender-affirming genital surgery that relies on testosterone-induced growth of clitoral tissue to create a small phallus. Without testosterone therapy, the procedure’s outcome may not achieve the desired surgical results. As such, individuals seeking Metoidioplasty are generally required to be on testosterone for at least one year before surgery, although intersex individuals may not need to meet this requirement.

Similarly, it’s recommended that those interested in Breast Augmentation undergo feminizing hormone therapy for a minimum of 12 months to optimize surgical outcomes.

8. Post-Surgical Care and Follow-Up The SOC stress the importance of post-surgical care and follow-up to ensure the patient’s health and satisfaction with the surgery results. This includes wound care, monitoring for complications, and providing emotional and psychological support through recovery. Ongoing support from both mental health professionals and the surgical team is recommended to help address any concerns that may arise after surgery.

9. Body Mass Index (BMI) The SOC do not set a specific Body Mass Index (BMI) requirement for gender-affirming surgeries. The SOC focus on the medical necessity of surgery, psychological readiness, and the ability to provide informed consent rather than setting rigid BMI guidelines. However, BMI may still be considered by surgeons as part of their medical assessment when determining if a patient is a suitable candidate for surgery. Also, BMI requirements are sometimes put in place by a surgical facility.

The WPATH Standards of Care provide a well-established, clinically recognized framework that supports the medical necessity of gender-affirming surgeries. Understanding more about the SOC requirements for surgery can ultimately make the process of pursuing gender-affirming surgery smoother, safer, and more empowering for patients.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

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