WPATH SOC-8: Changes to gender-affirming surgery in B.C.

In September 2022, the new WPATH Standards of Care for the Health of Transgender and Gender Diverse People Version 8 (SOC-8) was published.

Trans Care BC has worked, over a number of months, engaging with peer and clinical advisors to review the new standards of care and their implications for access to gender-affirming surgery in BC. This review has led to some changes that are intended to decrease barriers to care and increase the safety and quality of the care experience for those seeking gender-affirming surgeries.

We are pleased to share that as of February 16, 2023, some pathway and practice changes, in line with the WPATH SOC8 are being implemented in B.C. related to gender-affirming surgical care. 

A summary of these changes, along with commonly asked questions, are shared below. 

Are there any updates related to the WPATH SOC 8 criteria for accessing gender-affirming surgery?

Only 6 months of hormone therapy are required to access genital surgery or gonadectomy The surgical removal of either the testes or the ovaries. . (Previously, 12 months were required).

Congruent living is no longer a requirement to access genital surgery. (Previously, 12 months were required)

How does the surgical referral process work for gender-affirming surgeries?

As part of the surgical referral process for gender-affirming surgeries, care planning Process that a person, their health care providers, family and other supporters undertake in planning to reach their gender-affirming care goals. is an important step that begins before the referral for surgery.

As part of this process clients meet with a care planner to document or confirm their gender incongruence A mismatch between a person's gender and the sex they were assigned at birth. /dysphoria diagnosis, review their surgical goals, discuss the risks and benefits of gender-affirming surgery and determine readiness and the care plan for surgery and recovery. 

The care planner documents the important parts of the care planning conversations in a letter of recommendation that gets sent to the surgeon’s office along with the referral form.

As part of the new standards, only one surgical care planning letter of recommendation, is needed for all genital surgeries (previously, two letters of recommendation were required). This should improve access and wait times for surgical care planning (also called surgical readiness assessment An evaluation conducted by a health care professional to determine if a patient is ready to begin hormone therapy or have gender-affirming surgery. ). 

How many letters of recommendation are needed for genital surgery?

As of February 16, 2023, only one letter of recommendation is needed for genital surgery. Formerly, two letters of recommendation were required. 

Who can provide surgical care planning and a letter of recommendation for genital surgery?

There are important changes to who can provide surgical care planning and recommendations for genital surgeries (phalloplasty A gender-affirming lower surgery to create a penis and scrotal sac (phase 1) followed by testicular implants and implants to obtain rigidity/erection (phases 2 and 3). , metoidioplasty A gender-affirming lower surgery to create a penis. Metoidioplasty involves cutting ligaments around the clitoris to add length to the shaft and grafting skin around the shaft to create more girth. Optional additional procedures include scrotoplasty and urethral lengthening. , erectile tissue Tissue that is capable of stiffening or engorging with blood, which typically occurs during sexual arousal. (clitoral) release, vaginoplasty A gender-affirming genital surgery to create a vulva (including mons, labia, clitoris and urethral opening) and vagina. , and vulvoplasty A gender-affirming genital surgery to create a vulva (including mons, labia, clitoris and urethral opening) and remove the penis, scrotum and testes. Vulvoplasty creates the external aspects of a vulva without creation of a vaginal canal. ). 

Due to the complex nature of these procedures, only medical providers (MDs, NPs, and certain RNs) with the ability to support your care before and after surgery will be able to provide surgical care planning and recommendations for these surgeries. This change is intended to ensure that patients are well prepared and supported throughout their surgical journey.

I just completed surgical care planning for genital surgery with two non-medical providers, do I need to start this process over again?

Until April 1, 2023: Surgical programs will continue to accept recommendations from the old pathway (2 surgical recommendations completed by previously approved clinicians) until April 1, 2023.

This grace period means you can be referred for genital surgery with two surgical recommendations completed by previously approved clinicians, as long as the recommendations were done before April 1, 2023.

After April 1, 2023: All referrals must be made through the new pathway: 1 surgical recommendation by a medical provider on Trans Care BC's list of clinicians able to provide care planning for genital surgeries (MDs, NPs and certain RNs with the ability to support care before and after surgery.)  

How can I find a qualified surgical care planner for genital surgery?

Trans Care BC will continue to maintain a list of clinicians who are qualified to provide surgical care planning for genital surgeries. 

To find a qualified provider, or if you are concerned about what these changes mean for you, please contact the Trans Care BC health navigators.

How many letters of recommendation are needed for upper (breast and chest) surgery?

As before, only one letter of recommendation is required for  chest and breast construction A gender-affirming upper surgery (also called breast augmentation) that creates, enlarges or shapes one’s breasts by placing implants underneath natural breast tissue or muscle. surgeries.  

Who can provide surgical care planning and a letter of recommendation for upper (breast and chest) surgery?

Moving forward, BC clinicians can confirm that they meet WPATH World Professional Association for Transgender Health (WPATH) is a professional organization devoted to transgender health, whose mission as an international multidisciplinary professional association is to promote evidence-based care, education, research, advocacy, public policy and respect in transgender health. competencies to provide surgical care planning for upper surgeries. Trans Care BC has created a form to help with this confirmation.

Previously, providers needed to apply to Trans Care BC to be on a list of clinicians qualified to provide surgical care planning. This was a historical practice that pre-dated the program and was handed over when Trans Care BC began its work. A review of this step related to upper surgery has resulted in this change in practice.

This change is anticipated to reduce the wait times for surgical care planning.

Are there any updates for accessing gonadectomy surgery?

The process for gonadectomy is the same as for upper surgeries, as above.

Who can provide surgical care planning and a letter of recommendation for gonadectomy (hysterectomy, orchiectomy) surgery?

Moving forward, BC clinicians can confirm that they meet WPATH competencies to provide surgical care planning for gonadectomy surgeries. Trans Care BC has created a form to help clinicians with this step.

Previously, providers needed to apply to Trans Care BC to be on a list of clinicians qualified to provide surgical care planning. This was a historical practice that pre-dated the program and was handed over when Trans Care BC began its work. A review of this step related to breast and chest surgery has resulted in this change in practice.

This change is anticipated to reduce the wait times for surgical care planning.

I am a non-medical provider and have patients booked for genital surgery care planning, what should I do?

Until April 1, 2023: Surgical programs will continue to accept recommendations from the old pathway (2 surgical recommendations completed by previously approved clinicians) until April 1, 2023.

This grace period allows patients to be referred for genital surgery with two surgical recommendations completed by previously approved clinicians that were done before April 1, 2023.

After April 1, 2023: As of February 15, 2023, the surgical programs will accept surgical recommendations through the new pathway (1 surgical recommendation by a medical provider on Trans Care BC's list of clinicians able to provide care planning for genital surgeries). After April 1, all referrals must be made through this new pathway.

For more information, please connect with our Health Navigators.