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Page 6 of 20 Kant et al. Plast Aesthet Res. 2026;13:4

When presented with a surgical request that falls outside routine expectations but remains technically
reasonable, the behavioral health provider can play an important role in understanding the patient’s rationale
for the request, whether their expectations are reasonable, and whether the surgery is likely to help them
accomplish their gender goals . To some extent, this functions almost as an exercise in critical reasoning -
[32]
in the absence of longitudinal data, patients and providers must consider what is most important to the
patient and whether, given current knowledge, there is a realistic chance of achieving it. For example, a
patient who is interested in penile sparing vaginoplasty because they are focused on maintaining erectile
function may not have considered either the ways that the orchiectomy would impact function or the effects
on erectile function caused by the trauma to the pelvic area during dilation. Providers should also
contextualize any requests within the patient’s mental health and gender history and their current
psychosocial situation and help the surgeon determine whether the patient is making an informed choice
that they are well prepared to undergo, recover, and live with for the long term.

ADDRESSING POTENTIAL INDICATORS OF FUTURE RECOVERY CHALLENGES
As a result of experiences of minority stress, transgender individuals are at increased risk of a number of
mental health challenges that have the potential to make recovery from surgery substantially more difficult.
These challenges range in severity from those primarily associated with an increased risk of patient distress
to those that threaten to compromise surgical recovery. They include - but are not limited to - a history of
addiction, sexual assault, and body-focused repetitive behaviors (BFRB). Some sexually transmitted
infections also have the potential to affect healing during the perioperative period and may be more likely to
be disclosed to a behavioral health provider than in a surgical consult.

While not all of these concerns, even if present, will pose a challenge to every affected patient, providers
should be attuned to these risks and prepared to have open, trauma-informed discussions about the
challenges they may pose to recovery. Providers should also be prepared to create proactive treatment plans
that address these concerns within the specific domain of surgical recovery, and help identify both
professional and natural supports who can be called upon to provide assistance [3,33] . The following represent
some, but not all, of the common mental health challenges that can present specific obstacles to recovering
patients.

Self-harm and suicidality
Transgender and gender diverse individuals have been repeatedly shown to have significantly elevated rates
of self-harm and suicidality. This may be the result of experiences of minority stress, trauma, depression, and
other mental health difficulties. However, for some people, this can also reflect a need to take some control
or ownership over their own body - which they may not otherwise feel . Neither a history of self-harm nor
[34]
suicidal ideation is an inherent contraindication for surgery. However, individuals should be stable enough
that self-harm (e.g., cutting, burning) is not a primary coping skill and they are not experiencing active
suicidal ideation. (It is important to distinguish active suicidal ideation - where people are actively thinking
about how to end their life - from passive suicidal ideation - where they lack motivation to live but have no
plan or intention to die. Passive suicidal ideation remains a significant concern that should be addressed, but
it must also be contextualized within the individual’s social environment).

There is no specific timeline that can be followed to say that people are safe from further self-harm, suicidal
ideation, or suicide attempts . It is important to understand a person’s history of suicidal ideation and
[35]
injury (SI) and non-suicidal self-injury (NSSI) in order to assess its potential relevance to the perioperative
time period. Behaviors that occurred a single time, or in response to a specific event, are unlikely to recur
and are less of a concern than ongoing behaviors - particularly those that reflect a lower distress tolerance
than may be needed to deal with the inevitable stumbling blocks that occur both before genital surgery and
during recovery. Behavioral health providers should not just assess the history of these behaviors but
patients’ current coping strategies for managing likely concerns.