Behavioral Health Assessments and Surgical Readiness Letters for Gender-affirming Surgery: Current Literature, Standards of Care, and Practical Guidance.

purpose of reviewBehavioral health (BH) assessments play a key role in determining surgical readiness prior to gender-affirming surgery (GAS). These assessments evaluate mental health management preoperatively, psychosocial support postoperatively, and patient understanding of upcoming procedures. When conducting BH assessments, providers may also offer resources, support, and information, as needed. The resulting documentation, often referred to as a surgical readiness letter, can provide surgeons with relevant psychosocial context, enhancing understanding of patient needs, goals, and readiness. However, there is significant procedural heterogeneity in BH assessment prior to GAS, which has yet to become a nationally standardized process. RECENT

findingsWhile evidence continues to demonstrate the significant mental and physical health benefits of GAS, protocols for preoperative BH assessments vary widely due to a lack of standardized templates and limited language in current standards of care. Describing a patient’s experience of gender incongruence remains an integral component of the BH assessment. Emerging literature emphasizes collaborative, trauma-informed approaches, shifting from a pathology-driven framework to one of informed consent and support system evaluation. There is growing recognition that assessing (1) a patient’s access to mental health care, (2) stability of social support, and (3) understanding of perioperative care and recovery is essential to an effective BH assessment. Evidence suggests that comprehensive preoperative evaluation and psychosocial readiness are associated with better postoperative mental health outcomes. Studies also highlight the impact of GAS barriers on mental health outcomes. This review article: 1) evaluates recent literature on BH assessments for GAS, 2) explores the current standards of care, emerging best practices, and ongoing challenges shaping this continually evolving field, and 3) leverages institutional knowledge from a pioneer gender-affirming care center at a major academic medical institution in order to address gaps in current guidelines, providing readers with practical, detailed insights into conducting effective BH assessments that support adult patients preoperatively and optimize outcomes postoperatively.