Check eligibility for genital gender-affirming surgery
STEP 1 — Gather Information
Collect: persistent, well-documented gender dysphoria (diagnosis per DSM-5/ICD-10), legal age of majority, duration of continuous and responsible gender-affirming hormone use (if no contraindication), duration of successful continuous full-time living in the affirmed gender role, status of any significant medical or mental health conditions, and patient’s demonstrable knowledge of surgical practicalities (cost, hospitalization length, likely complications, postsurgical rehabilitation).
STEP 2 — Rule In / Rule Out
Is the patient of legal age of majority in their country? If NO → not eligible for genital gender-affirming surgery; if YES → proceed to evaluate hormone use and real-life experience.
STEP 3 — Classify or Stratify
Assess whether the patient has used gender-affirming hormones continuously and responsibly for ≥12 months (or has a documented medical contraindication) AND has lived full-time in the affirmed gender role for ≥12 months. If both criteria are met → move to medical/mental health check; if either is NOT met → defer surgery until criteria are satisfied.
STEP 4 — Decide
If significant medical or mental health concerns are present, are they well controlled? AND does the patient demonstrate knowledge of all practical surgical aspects? If YES to both → patient is eligible for referral for genital gender-affirming surgery; if NO → address uncontrolled conditions or provide education before reconsideration.
Clinical Guardrails / Mimics / Pitfalls
Do not proceed to surgery if significant psychiatric or medical instability exists (e.g., uncontrolled psychosis, active substance use, unstable cardiovascular disease). Avoid surgery based solely on hormone desire without confirming persistent gender dysphoria and real-life experience. Never bypass the requirement for informed understanding of surgical risks, outcomes, and postoperative care.
Concrete Clinical Example
A 23-year-old trans man on testosterone for 16 months, living full-time as male for 15 months, with well-controlled anxiety, and who can articulate surgical costs, hospitalization, and postoperative dilation requirements, meets all criteria and is referred for metoidioplasty with urethral lengthening.
Source: Endocrine Society Clinical Practice Guideline, Endocrine Society, 2017, doi:10.1210/jc.2017-01658