Medical considerations Some medical conditions, including
diabetes,
asthma, and HIV, can lead to complications with future therapy and pharmacological management. 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
endocrinologists, whom the surgeon may consult when determining if the patient is physically fit for surgery. 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. 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. 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. Preferred treatments for children include
puberty blockers and
gender affirming hormone therapy, which reduces 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. This is controversial because of the
human rights implications. 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.
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
disorder.
Standards of care 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. 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. 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. 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. 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.
Insurance 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). 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." Other organizations have issued similar statements, including WPATH, == Post-procedural effects ==