The Standards of Care for the Health of Transgender and Gender Diverse People (SOC) is an internationally recognized clinical protocol developed by the World Professional Association for Transgender Health (WPATH). The SOC provides evidence-based guidelines for the assessment and treatment of transgender and gender-diverse individuals, covering social, hormonal, and surgical aspects of gender transition. Based on the latest scientific research and expert consensus, these guidelines ensure that individuals receive ethical, respectful, and high-quality care. The most recent edition, SOC Version 8, was published in 2022.
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.