COVID-19 Increases Barriers to Gender-Affirming Surgeries

Transgender and non-binary patients seeking gender-affirming surgeries, such as a mastectomy or genital reconstruction, are required to provide a letter from a trained mental health provider in order to receive clearance for surgery. However, the COVID-19 pandemic led to cancellation of many elective surgeries and saw numerous mental health letters expire prior to the surgery date.

“We have to make sure they have their mental health letters ready, and make sure their mental and physical health is ready before surgery. Finally, eight months later, they see the surgeon and those letters they got for mental health are going to expire because they won’t be dated within one year of actual issue date. They have to go back to mental health providers,” said Kavita Mishra, clinical assistant professor at Stanford University and recent fellow in transgender surgery and medicine from the Cleveland Clinic.

Mishra said this could create financial limitations for a transgender or non-binary individual who has to be able to see a therapist or provider again to get an updated later. 

“They shouldn’t have to pay all this money to see a second mental health provider and end up in these time loops,” said Mishra. 

Mishra said aside from possible six–eight month delays in surgery requests, there is also the issue of finding a mental health provider who feels comfortable with writing a referral for a gender-affirming surgery. 

“Many mental health providers, just like medical providers, do not have experience caring for gender minorities and may not feel comfortable writing a letter of support. So, a patient will then have to find the right provider in their state, willing to write a letter, and covered by insurance. Then do this twice,” said Mishra. 

Prior to the emergence of COVID-19 pandemic, research showed that transgender and non-binary individuals experienced barriers to care, greater mental health challenges, and economic vulnerabilities caused by stigma, discrimination, and minority stress. 

These barriers to care were made worse by the pandemic, as a multi-national survey begun in May 2020 and ongoing, found that of 4,699 participants undergoing transition-related treatment or planning to do so, about 61%, or 2,875 individuals, feared access restrictions to transgender health care in the future due to the COVID-19 pandemic.

For the 3,463 participants who had already undergone transition-related treatment, about 50%, or 1,706 individuals, experienced restrictions in access to transgender health care services. 

In 1979, the World Professional Association for Transgender Health, known as WPATH, established standards of care for the proper protocols to treat gender dysphoria and the process for obtaining a gender-affirming surgery or procedure. 

The American Psychological Assocation defines “gender dysphoria,” as psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity, that can often lead to negative mental health outcomes such as depression and anxiety.

According to the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7, a clinical diagnosis of gender dysphoria, transsexualism, or gender identity disorder is required prior to any referral for a gender affirming surgery. 

Mishra said that almost all centers in the U.S. follow the WPATH standards of care, and many mental health professionals will state in their mental health letter that they are following the WPATH standards when referring a patient for a gender-affirming surgery. 

“For most surgeries, only one letter is required, but for any genital or ‘bottom’ surgery, two letters are required. Many insurance companies require these standards be followed before covering surgery. Some insurance plans have such limited mental health coverage, not to mention patients having poor access to mental health services where they live, that they have to pay out-of-pocket for consults,” said Mishra.

“I think insurance plans are generally doing a better job covering mental health services than before, but what about a patient who is in great mental health, has no dysphoria but desires surgery, and has to get a letter to check the box?” asked Mishra.