Gatekeeper or Pathfinder? Reimagining the Role of the Mental Healthcare Provider in Gender Affirming Surgery Referral

Mental healthcare and gender affirming surgery (GAS) have been tightly intertwined since the advent of medical gender transition. Mental health assessment still plays a pivotal role in access to GAS. Currently, the World Professional Association of Transgender Health (WPATH) requires two independent mental health assessment letters on behalf of patients seeking genital surgery (Coleman et al., Int J Transgend 13:165–232, 2012). This requirement has been a source of significant controversy, drawing criticism from members of transgender and nonbinary (TGNB) communities (Brown et al., Prof Psychol Res Pr 51(6):571–579, 2020; Puckett et al., Sex Res Soc Policy 15(1):48–59, 2018) and mental health professionals alike (Puckett et al., Sex Res Soc Policy 15(1):48–59, 2018; Chang et al., A clinician’s guide to gender-affirming care: working with transgender and gender non-conforming clients. New Harbinger Publications, Oakland, 2018). At the core of this controversy is the question: who decides the conditions under which transgender people access GAS? In this chapter, we discuss how the history of mental healthcare in gender affirming has influenced current approaches to the pre-surgical mental health assessment. We then seek to highlight how current practices have evolved to more effectively address the needs of the transgender community. Finally, we make recommendations for surgeons, mental healthcare providers, and policymakers on how they might effectively collaborate to promote safe and satisfactory surgical outcomes for transgender and nonbinary patients.