{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T22:37:45Z","timestamp":1776119865524,"version":"3.50.1"},"reference-count":34,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2021,9,14]],"date-time":"2021-09-14T00:00:00Z","timestamp":1631577600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Andrology"],"published-print":{"date-parts":[[2021,11]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>The World Professional Association for Transgender Health (WPATH) recommends referral letters\u00a0from two mental health providers within one year of gender\u2010affirming genital surgery\u00a0(gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second\u2010 and third\u2010stage surgeries or revision surgeries without two referral letters.\u202fSuch requirements\u00a0are not supported by WPATH guidelines.<\/jats:p><\/jats:sec><jats:sec><jats:title>Objectives<\/jats:title><jats:p>This study investigates insurance\u00a0requirements for\u00a0referral letters and their negative impact on care.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and methods<\/jats:title><jats:p>We retrospectively reviewed\u00a0all\u00a0gGAS\u00a0cases\u00a0over a 4\u2010year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented.\u00a0The nation's largest insurance companies, including commercial, state\u2010, and federally funded plans, were\u00a0contacted to confirm requirements.\u00a0We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH\u00a0publications\u00a0were reviewed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Nearly all reviewed U.S. health insurance plans required\u00a0annually\u00a0updated referral letters for each gGAS procedure, including staged and revision surgeries.\u00a0No updated letters changed clinical management.\u00a0Referral letter requirements delayed care.\u00a0WPATH states that letters should not be needed for staged surgeries.\u00a0Some plans required letters even for initial surgical consultation, a practice not supported by WPATH.<\/jats:p><\/jats:sec><jats:sec><jats:title>Discussion and Conclusion<\/jats:title><jats:p>Insurance companies\u2019 requirements for referral letters impede care and contradict WPATH guidelines.\u00a0We advocate that, at minimum,\u00a0referral letters should not be required for surgical consultations or for staged or revision surgeries\u00a0after a patient has already had first\u2010stage primary\u00a0gGAS. Universal\u00a0referral letter\u00a0requirements\u00a0provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition.\u00a0As with all procedures, surgeons themselves should be responsible for assessing patients\u2019 surgical readiness.\u00a0Significant changes in mental health status or social situation should prompt surgeons to seek reassessment.\u00a0WPATH recommendations\u00a0regarding\u00a0referral letters\u00a0should be clarified and consolidated into a single document.<\/jats:p><\/jats:sec>","DOI":"10.1111\/andr.13028","type":"journal-article","created":{"date-parts":[[2021,5,8]],"date-time":"2021-05-08T19:16:27Z","timestamp":1620501387000},"page":"1765-1772","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Requirement of mental health referral letters for staged and revision genital gender\u2010affirming surgeries: An unsanctioned barrier to care"],"prefix":"10.1111","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8182-0921","authenticated-orcid":false,"given":"Nance","family":"Yuan","sequence":"first","affiliation":[{"name":"Cedars\u2010Sinai Transgender Surgery and Health Program Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Urology Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Plastic Surgery Cedars\u2010Sinai Medical Center Los Angeles CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Theodore","family":"Chung","sequence":"additional","affiliation":[{"name":"David Geffen School of Medicine University of California Los Angeles CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Edward C.","family":"Ray","sequence":"additional","affiliation":[{"name":"Cedars\u2010Sinai Transgender Surgery and Health Program Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Plastic Surgery Cedars\u2010Sinai Medical Center Los Angeles CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Caitlin","family":"Sioni","sequence":"additional","affiliation":[{"name":"Cedars\u2010Sinai Transgender Surgery and Health Program Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Urology Cedars\u2010Sinai Medical Center Los Angeles CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alma","family":"Jimenez\u2010Eichelberger","sequence":"additional","affiliation":[{"name":"Cedars\u2010Sinai Transgender Surgery and Health Program Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Urology Cedars\u2010Sinai Medical Center Los Angeles CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6165-1200","authenticated-orcid":false,"given":"Maurice M.","family":"Garcia","sequence":"additional","affiliation":[{"name":"Cedars\u2010Sinai Transgender Surgery and Health Program Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Division of Urology Cedars\u2010Sinai Medical Center Los Angeles CA USA"},{"name":"Departments of Urology and Anatomy University of California San Francisco CA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2021,9,14]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1080\/14737167.2017.1388164"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ajp.2019.19010080"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11136-010-9668-7"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1055\/s-0037-1608656"},{"key":"e_1_2_7_6_1","first-page":"1849","article-title":"The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International","volume":"16","author":"Al\u2010Tamimi M","year":"2019","journal-title":"Multi\u2010Center Case Series. 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