Assessment of Behavioral Health Readiness for Gender-Affirming Surgery: A Cross-Sectional Survey of Mental Health...

Introduction Gender-affirming surgery (GAS) is associated with improved mental health and quality of life outcomes for transgender and nonbinary (TGNB) individuals; however, access to GAS often requires preoperative behavioral health readiness evaluations, as outlined by the World Professional Association for Transgender Health, which result in a letter of surgical readiness. Little is known about how mental health providers (MHPs) conduct preoperative readiness assessments in current practice. This cross-sectional study assessed how MHPs evaluate surgical readiness prior to GAS and examined differences in assessment approaches by provider training, experience, and gender identity. Methods A 25-question survey was developed by the research team and administered electronically using the Johns Hopkins University Research Electronic Data Capture (REDCap) platform. Eligible participants included MHPs in Maryland and the District of Columbia listed on Psychology Today who identified "transgender" as an area of competency. Responses were grouped by respondent training, evaluation volume, and gender identity. Assessment methods, prioritized psychosocial domains, and potential referral barriers were compared using Chi-square/Fisher's exact tests. The number of sessions and assessment outcomes between groups were compared with one-way analysis of variance. The survey was distributed to 462 unique email addresses and remained open for six weeks from October 14 to November 30, 2022. Results Of 462 MHPs, the response rate was 21% (n=97). Among respondents with complete data for both variables, MHPs who attended conferences to augment their training found more value in the letter-writing process compared to those who did not attend conferences (n=29/46 (63%) vs. n=9/28 (32.1%); p=0.028). The inability to provide informed consent (60.8%, n=59/97) and unrealistic expectations (46.4%, n=45/97) were the most frequently cited factors that would preclude a letter of surgical readiness. A significantly higher proportion of TGNB MHPs considered unrealistic expectations to be a contraindication to referral compared to cisgender MHPs (n=16/18 (88.9%) vs. n=29/56 (51.8%); p=0.005). The median (interquartile range) number of sessions needed between letter request and referral for surgery was 2 (1-4). A median (interquartile range) of 95% (85%-100%) of clients were granted referral. Conclusion Approaches to preoperative evaluation varied. Experienced, high-volume MHPs and TGNB MHPs emphasized the capacity for consent, autonomy, and realistic surgical expectations over their peers. Formalized training in TGNB care increased perception of letter value.