Letters Before Gender-Affirming Surgery: SOC-8 and Thai Criteria

Many trans patients come to me asking, "Can you write my surgery letter, doctor? How many do I need?" This is harder to answer than you might think, because international guidelines and the criteria Thai hospitals actually use still differ. This article explains both, so your planning goes smoothly. This is especially useful if you have travelled to Thailand for surgery.

Why is an assessment needed before surgery?

Many gender-affirming surgeries are permanent changes, such as chest or breast surgery, removal of the testes or ovaries, and genital surgery. The assessment isn't there to "judge" whether you're really trans, but to make sure that:

• You understand the results, limitations and risks of the surgery.
• You have thought about fertility, because removing reproductive organs means you can no longer have genetic children.
• Your physical and mental health are ready for surgery and recovery.
• You have people around you or a support system for the period after surgery.

WPATH SOC-8 (2022) guidance for adults

SOC-8 makes the criteria clearly more flexible than the previous version (SOC-7):

1. Gender incongruence is marked and sustained.
2. You are able to consent to the specific surgery.
3. You understand the effect on fertility and have been informed about options for preserving eggs or sperm.
4. Physical and mental health conditions that might affect surgical outcomes have been assessed and addressed.
5. For surgeries where hormones affect the result, such as removal of the testes or ovaries and genital surgery, about 6 months or more of stable hormone therapy is suggested, unless hormones are not wanted or are medically contraindicated.

What has changed: adults can rely on the opinion of one qualified professional, two letters are no longer needed for genital surgery, and there is no longer a requirement to "live in the affirmed gender role" for a fixed period before surgery. Chest surgery for trans men does not require prior hormone therapy.

Criteria actually used in Thailand

In Thailand, the Medical Council has had regulations on criteria for sex reassignment treatment since 2009 (B.E. 2552), and most hospitals still refer to them. In practice, common requirements include:

These criteria may be updated in future, and each hospital may add its own conditions. The surest approach is to ask the surgical team from the start which documents they need, how recently letters must be issued, and which kind of specialist must write them. If you are coming from abroad, also ask whether letters from your home country are accepted or whether assessment must be done in Thailand.

WPATH SOC-8 (2022)

Adults

• One qualified professional's opinion is enough
• Stable hormones for about 6+ months (some surgeries)
• No required period of living in gender
• Chest surgery in trans men needs no prior hormones

Commonly seen in Thailand

Based on Medical Council rules 2009

• Genital surgery usually needs 2 psychiatrists
• Hormones for roughly 1 year
• Living in the stated gender for roughly 1 year
• Age 20+, or 18-20 with parental consent

vs

Each hospital may set its own rules. Ask the surgical team from the start which documents you need.

Who can diagnose and write an opinion?

Under SOC-8, assessors should be licensed professionals with knowledge of gender identity, ICD-11 and DSM-5-TR, and experience caring for trans people. In Thailand, the psychiatric assessment for genital surgery usually has to be done by a psychiatrist.

The role of the doctor managing your hormones, such as a family physician, is to assess your overall health, summarise your hormone history and blood results, prepare your body, and refer you to the appropriate psychiatrist or surgical team.

Getting ready

1. Summarise your hormone history: medicine names, doses, how long you've used them, and past blood results (see blood tests before starting hormones).
2. Manage existing conditions such as high blood pressure, diabetes or anaemia so they are controlled before surgery.
3. Stop smoking for at least several weeks before and after surgery to reduce the risk of slow wound healing and blood clots.
4. Discuss hormones around surgery. Some teams ask you to pause estrogen temporarily before major surgery to reduce clot risk. Follow your surgical team's advice; don't stop or restart on your own.
5. Plan for fertility. If you want to, bank sperm or freeze eggs before surgery on reproductive organs.
6. Test for HIV and STIs according to your risk.
7. Prepare emotionally and arrange support. Recovery can be physically and emotionally tiring, and having someone close or a therapist helps a great deal.

1. 1Summarise hormone historyDrug names, doses, duration, past blood results
2. 2Prepare your bodyControl chronic conditions; stop smoking for weeks before and after
3. 3Plan hormonesFollow the surgical team; don't stop or start on your own
4. 4Children + STI testsStore sperm or eggs if wanted; HIV and STI tests by risk
5. 5Prepare mind, carerRecovery can be tiring physically and emotionally

After surgery, don't forget your hormones

If your testes or ovaries are removed, your body no longer makes its own sex hormones, so you need continued hormone replacement. Trans women can often reduce or stop anti-androgens, while trans men need to continue testosterone. Read more in do trans men still need hormones after removal of the ovaries? and feminising hormone therapy.

How Dr. Kris Clinic can help

At Dr. Kris Clinic, I care for your hormones and overall health before surgery, summarise your treatment history and blood results for referral, offer counselling around the decision, and help coordinate referrals to psychiatrists and surgical teams according to the criteria of the hospital you choose. After surgery, I can continue your hormone care, at the clinic in Surat Thani and online, with English-speaking consultations available. For the overview, read gender-affirming hormone therapy (GAHT).