Readiness assessments prior to gender affirming medical care: The processes and perspectives of Australian healthcare practitioners.

Table 1 presents participant demographics for the final sample who completed the full survey ( N  = 14;). Nine psychologists and one medical practitioner, comprising a mix of genders including TGDNB clinicians, participated in an interview ( N  = 10). Participants were free to self-describe their gender. Given relatively few HCPs administer readiness assessments, and two qualitative themes generated in our results related to concerns about repercussions of this work (including litigation and fear of violence), we have chosen not to report the specific demographics of participants or the specific medical disciplines of the medical practitioners who participated to avoid accidental identification and potential risk to these participants. We have also chosen not to assign pseudonyms to participants for these same reasons. Participant demographics. Participants had been conducting readiness assessments for several years ( M  = 3.25, SD = 1.20; range = 1—8), had conducted an average of 39.36 (SD = 50.37; range 4 - 200) across their career, and conducted assessments over one to six appointments ( M  = 3.5, SD = 1.4). All participants ‘agreed’ or ‘strongly agreed’ they could competently conduct readiness assessments. Thirteen participants (92.86%) ‘disagreed’ or ‘strongly disagreed’ with the statements ‘My university education gave me adequate training in administering readiness assessments’ and ‘My university education gave me adequate training in working with trans, gender diverse, and non-binary clients’. While participants were confident in their abilities, these results demonstrate readiness assessment skills were not developed during university training. All but one participant (92.86%) reported they had attended specialized training/workshops or conferences as part of their professional development in the area, with an average of 41.12 h (SD = 34.37; range 0—100) spent in training or supervision specific to readiness assessments. Descriptive means for participant’s understanding of each SoC criterion are presented in Figure 1 while descriptive means for participant’s confidence assessing each criterion are presented in Figure 2 . Overall, participants reported an excellent understanding of each criterion and were very to extremely confident in their ability to assess each criterion. Self-rated understanding of each SoC v8 summary criterion. Self-rated confidence assessing each SoC v8 summary criterion. Table 2 reports the frequency of all free-text responses to participant’s understanding and assessment of the WPATH SoC v8 summary criteria. An overview and summary of responses is provided below. Frequency of free-text responses to participant’s understanding and assessment of the WPATH SoC v8 summary criteria. Note . ‘Response frequency’ relates to how many times this response was reported by one participant, thus, the maximum response frequency possible for each response is 14. Criterion A requires assessment of two components of gender incongruence (GI), its nature as (i) marked and (ii) sustained. Therefore, participants were asked about these separately. Fifty percent of responses related to GI needing to impact mental health and/or functioning to be marked, while 25% related to a dislike of gender assumed at birth and a further 25% related to a desire for gender affirmation/transition. The markedness of GI was mostly assessed via clinical interview, with one third also utilizing standardized measures. Most participants (60%) provided a nonspecific timeframe for how long they believed GI needed to be present to be considered sustained, however, most did reference the need for a prolonged period. Three participants considered six to 12 months as sustained. The sustained nature of GI was mostly assessed via clinical interview and differential diagnostic processes. A broad range of responses were provided for criterion B. Most participants (73%) used clinical interview to assess and diagnose GI and/or gender dysphoria. Just over half (53%) used the International Classification of Diseases (ICD) or Diagnostic and Statistical Manual of Mental Disorders (DSM) in their diagnostic process, while just 40% relied on standardized questionnaires to support diagnostic decisions. All participants reported more than one method or factor for consideration in their diagnostic process. Most participants (86%) reported a client’s capacity to consent involved an understanding of the risks and benefits of treatment, with 50% also requiring a client to recall this information across appointments, ensuring understanding is maintained over time. One third of participants referred to some form of informal cognitive assessment in determining capacity and one third also reported assessment of mental health as important to assessing capacity. One quarter include a discussion of potential future regret, and one quarter include a discussion of client’s expectations and hopes for GAMC, in their determination of capacity. Two-thirds of participants reported they assessed for presence of dissociative disorders, and over half (53%) reported assessing for psychotic disorders, as possible alternative causes of GI. Body dysmorphic disorder (BDD) and trauma were also regularly reported by participants as possible alternate causes. There was a broad range of other medical, psychological, and social issues (such as bipolar disorder, temporal lobe epilepsy, and others) that were reported by either one or two participants. Responses regarding which mental and/or physical health conditions they believed could impact treatment outcomes were the broadest and most inconsistent of all criteria. Of the 29 distinct responses to this question, only two (depression and psychotic disorders) were reported by more than two respondents (both reported by three respondents). In fact, 21 were responses were only reported one time and a further six were reported by only two participants. Most participants (86%) assessed for these concerns via clinical interview, with 43% also using standardized questionnaires. Three participants (21%) also reported consulting other HCPs. Three psychologists reported not assessing for physical health conditions, choosing to leave this to a medical practitioner. All participants reported discussing reproduction with clients. Eleven participants (78%) reported discussing the fertility impacts of GAMC in the assessment, with eight (57%) also discussing fertility preservation options. Discussions regarding family planning and future desire for children were reported by seven participants (50%) and six (43%) encouraged clients to discuss fertility and possible preservation with a medical practitioner. Three participants (21%) discussed possible future regret regarding fertility decisions. The interviews ( N  = 10) focused on learning more about how clinicians conducted readiness assessments, their understandings of the purpose of assessments, what challenges they have experienced while conducting these, and any needs they had in relation to assessments. The most common responses regarding the purpose of readiness assessments referenced client capacity to understand and make an informed decision regarding GAMC. “Informed consent” was mentioned 44 times across interviews, with most participants providing some variation on “it’s an assessment of the client’s capacity to give informed consent for the procedure they’re planning to undergo” (P5). Interestingly, participants more readily suggested assessments helped medical practitioners feel more confident in patient’s understanding of the treatment than they suggested assessments supported the informed decisions of clients themselves. P8: It is a process to reassure the surgeon or endocrinologist or GP who is considering endeavouring to provide [GAMC], that the patient has capacity to consent… and that there is no mental illness of such severity that it could impair their capacity or ability to consent or could impair their ability to recover after surgery. Comments regarding informed consent were tempered by participants’ concerns regarding the varied domains they were expected to assess, including physical health and fertility: P1: I can assess capacity to understand, but I do not feel it’s in my wheelhouse … to fully explain the medical benefits and risks… if they ask me what specific procedures are around egg retrieval, I wouldn’t be able to tell them in detail. If they are seeking a double mastectomy and they have a history of breast cancer, I understand that there is some relationship between those two and that that needs to be looked at closely. But I have no further knowledge about what that conversation should look like. P9: We take a physical health history, but we’re not medical doctors … We don’t know if someone’s medical condition’s going to interact with their hormones or it’s gonna increase their chance of developing an infection after surgery or whatever it might be. Thus, while participants acknowledged the importance of establishing ability to consent, the perception was that this was more for other HCPs than the client, and that in some cases they were unable to assess this due to their own lack of understanding of medical intervention. P1: I can assess capacity to understand, but I do not feel it’s in my wheelhouse … to fully explain the medical benefits and risks… if they ask me what specific procedures are around egg retrieval, I wouldn’t be able to tell them in detail. If they are seeking a double mastectomy and they have a history of breast cancer, I understand that there is some relationship between those two and that that needs to be looked at closely. But I have no further knowledge about what that conversation should look like. P9: We take a physical health history, but we’re not medical doctors … We don’t know if someone’s medical condition’s going to interact with their hormones or it’s gonna increase their chance of developing an infection after surgery or whatever it might be. This theme highlighted how assessments can support positive GAMC outcomes e.g. “(so) that people undergoing [GAMC] have the best outcomes possible” (P1). Several participants believed assessments led to a more planned and safer journey, noting that some considerations might not be explored in depth in the IC pathway and that an assessment provided an “entry point into systems of care, systems of support, systems of psychoeducation, if they want it… provided the opportunity for me to engage them with care, which otherwise, they would’ve never sought that out” (P4). P4: There are certainly benefits to having a little more time and space to explore complex questions, like, fertility… Like, what are actually going to be the risks and challenges you face, not just the physical changes, but what will that mean for what bathrooms you use or what’ll that mean for coming out at work and will that threaten your employment? Or what’ll that mean for addressing issues of like, sex or things in your relationship? Assessments were seen to support opportunities to explore, and improve, overall mental health and functioning. For example, participants acknowledged that TGDNB clients often experience mental health concerns unrelated to their gender, and that exploring how these challenges might impact GAMC outcomes was important. Participants emphasized that the presence of mental health difficulties did not need to impede GAMC access, but that planning to ensure outcomes were not impacted is beneficial: P1: It’s quite rare that I would see someone who is coming to me that’s not feeling depressed, but it’s also about are they so depressed that they’re not going to be able to physically care for themselves after undergoing bottom surgery. Similarly, participants reported assessments allowed clients who saw GAMC as a panacea to address every concern an opportunity to reexplore their expectations and other goals: “Probably when I’ve had to slow things down is when clients think that it’s just gonna fix everything for them, particularly if there’s comorbid mental health complaints. So the client saying, “Oh, this will make everything better” (P3). P1: It’s quite rare that I would see someone who is coming to me that’s not feeling depressed, but it’s also about are they so depressed that they’re not going to be able to physically care for themselves after undergoing bottom surgery. Litigation was mentioned by nine participants, including (i) the impression that readiness assessments existed to provide litigation protection for prescribers and surgeons and (ii) their own concerns about litigation (discussed below under challenges). For example, P9 reflected “it’s the doctors needing that reassurance they’re doing the right thing… That covers them medically, legally”. This was echoed by P4: P4: If that medical provider gets sued, they can say there was an assessment done and this person was kind of referred and in their right mind and it was, yeah, their decision… So, surgeons practice with a lot of like, caution and fear in mind in terms of erring on the side of not wanting to get sued. Taken together, participants saw readiness assessments as ensuring clients could provide informed consent for treatment, to support them to receive positive outcomes of treatment, and to assist practitioners in avoiding litigation. P4: If that medical provider gets sued, they can say there was an assessment done and this person was kind of referred and in their right mind and it was, yeah, their decision… So, surgeons practice with a lot of like, caution and fear in mind in terms of erring on the side of not wanting to get sued. At 49 references, systemic challenges were the most common code in the data set, reflecting diverse concerns with the current systems for accessing GAMC. Issues included (i) surgeons requiring multiple assessments (in contrast WPATH SoC v8 which requires only one for all GAMC), (ii) assessment outcomes and reports ‘expiring’ after a few months, (iii) acceptance of assessments only from clinical psychologists or psychiatrists, and (iv) assessments being mandatory before all surgeries. These challenges were seen to negatively impact clients by increasing wait times and the financial burden of GAMC. P3 expressed this well by reflecting that sometimes clients may have been living in their affirmed gender for much of their life but are still required to complete an assessment: “I think maybe we’re lying to ourselves as clinicians, trying to justify the… stuff we put in place when clients might have spent decades wanting this”. While most participants saw that support via appointments with a HCP could be valuable for some, all expressed concern that readiness assessments were pathologizing, unfair, and/or gatekeep necessary medical treatment, particularly when made mandatory for some GAMC (such as gender affirming surgeries). This led most participants to support an IC pathway to surgery: “For many seeking top surgery, I’d also suggest informed consent by the surgeon should be sufficient” (P5). Most participants also went beyond just whether assessments should be optional and questioned whether assessments should exist at all, with comments ranging from basic concerns of inequities: “there are many other surgeries and treatments that don’t require a mental health assessment” (P9) through to complete rejection of the process “I don’t think they should exist” (P6); “it’s a complete waste of time and a load of old nonsense. The sooner it’s got rid of, the better.” (P8). Inequity was highlighted by many participants in the context of cis individuals accessing similar surgeries without formal assessment and how this impinged on TGDNB rights. For example, P4 highlighted that a trans woman would need assessment before breast augmentation, but that no such process is automatically required for cis women seeking the same procedure: “Why do trans folks need an assessment and sessions with psychologists or psychiatrists for, say, a breast augmentation when a cisgender woman can just go and get one?”. P2 echoed this perceived double standard: “I think typically these are very well thought out decisions whereas people kind of have the freedom to make really dumb decisions all the time and we don’t make them justify that”. Participants highlighted personal safety concerns and how this might impact their ability to work in the space, for example, P1 worried “… about physical repercussions… I am worried about someone … harming me because of the work that I do”. P1, who grew up in the USA, also highlighted: “One of my main fears is that Australian governments … will start moving in the direction that America has… it’s terrifying… If I did what I do right now in Florida, I would literally be arrested”. P4 echoed this because of their experience as a trans clinician: “a little bit of fear of like, dragged through the mud by Right Wing Media. Or found by Nazis and doxxed. Or hate crimed in some other way”. Participants shared concerns about treatment in the media, courts, and by governments. Many worried about how they might be treated if a client later regretted GAMC. Worries about future litigation in such instances were commonly reported (e.g. “I think there is legal stress, like stress around potential legal repercussions” [P2]; “I have fear of being sued by a client. So, facing legal consequences, being sued and needing to defend all of my decisions in that kind of context.” [P4]). Some participants balanced these concerns against their clinical responsibility (e.g. “… that would cover my ass more legally, but is that actually in the client’s best interest?” [P3]). Overall, participants were concerned that readiness assessments were heterogenous. Participants knew of differences in assessment processes as well as differences in what was requested from prescribers and surgeons. More than half of participants desired more guidance, standardization, and/or specific training and accreditation in conducting assessments. P10 summarized this: P10: Can we just have some guidance and some agreement professionally? … This is what we want, if you cover off this stuff and if your [registration body] says you are competent to do that, then can that just be enough? … Cause otherwise it feels we are going through hoops as well. Participants also noted that the WPATH SoC were necessarily broad to accommodate flexibility, but that this brought challenges: P4: within the current [SoC] … there is purposeful broadness, so that it can be applied in different ways and across different countries and contexts. But I think we can really get lost in that broadness of, well, what actually are we doing and why? Further, the SoC uses the ICD-11 diagnosis of gender incongruence despite the DSM 5 TR (with its diagnosis of gender dysphoria ) being more commonly used by Australian HCPs. Some participants compared these two diagnoses, viewing the DSM 5 diagnosis as more pathologizing: “They also meet criteria for gender incongruence, which is much more inclusive and less pathologizing. So, I then include that, but there have also been times when I’ve had to diagnose gender dysphoria and it feels gross” (P1). P10: Can we just have some guidance and some agreement professionally? … This is what we want, if you cover off this stuff and if your [registration body] says you are competent to do that, then can that just be enough? … Cause otherwise it feels we are going through hoops as well. P4: within the current [SoC] … there is purposeful broadness, so that it can be applied in different ways and across different countries and contexts. But I think we can really get lost in that broadness of, well, what actually are we doing and why?

Using a mixed-methods approach, we sought to understand Australian HCPs’: processes for administering readiness assessments; understanding of the purpose of readiness assessments; and concerns regarding readiness assessments. processes for administering readiness assessments; understanding of the purpose of readiness assessments; and concerns regarding readiness assessments.

Ethics was obtained from the host university ethics committee. Consultation with TGDNB lived experience community members who had completed a readiness assessment occurred during the development of this study, including seeking guidance on gender-affirming question development, language, and analytic approach. Recruitment occurred via email invitation to the mailing list of the Australian Professional Association for Trans Health (AusPATH). AusPATH is Australia’s leading body representing, supporting, and connecting professionals working in trans healthcare. Participants were required to rely on the WPATH SoC v8 criteria in their administration of readiness assessments to participate. Participation involved completion of an online survey (approx. 20–30 min in duration) and participation in a 1:1 semi-structured interview. The survey collected demographic information (e.g. age, gender, profession, broad location) and contained questions regarding participant’s background and processes when conducting readiness assessments. Background questions explored number of assessments conducted over their career, level of training/support received. Participants then rated their understanding of what each criterion means/is asking (‘poor’ = 1, ‘average’ = 2, ‘good’ = 3, ‘excellent’ = 4) and how confident they are in assessing each criterion (‘not confident at all’ = 1, ‘moderately confident’ = 2, ‘very confident’ 3, ‘extremely confident’ = 4). Finally, the survey investigated participants’ understandings of, and assessment processes for, each of the WPATH SoC v8 summary criterion A through F (Coleman et al., 2022 ; e.g. “(Criterion A): Gender incongruence is marked and sustained: (i) What is your understanding of what makes gender incongruence marked, and how do you assess that? (ii) What is your understanding of what makes gender incongruence sustained, and how do you assess that?”). In comparison to previous investigations (e.g. Westmacott et al., 2024 ) where participants were provided with predetermined category responses to their assessment practices, our survey allowed free-text responses to collect nuanced and specific data. At the end of the survey, participants were invited to engage in the 1:1 semi-structured interview to further explore their perspectives (see Appendix for interview questions). All interviews were conducted via Zoom by a research team member and were recorded for later transcription by Scribie. Participants received a $50 online gift card following participation in the interview. Due to small sample size, descriptives, frequencies, and content analysis were used to explore survey data. The first author and a research assistant extracted a frequency count for each free-text response. Responses were categorized together where they were deemed to represent the same inherent response (e.g. “clinical interview” and “collecting an appropriate client history via interview” were categorized as “clinical interview”). Responses were categorized under general themes where possible (e.g. “Marked is when gender incongruence has impacted their mental health” and “Significant to the person’s mental health, functioning and quality of life” were categorized under the theme “Gender negatively impacting mental health and/or functioning”). Disagreements in categorization were discussed until consensus was reached. Reflexive thematic analysis (Braun & Clarke, 2021 ) was applied to interview data. Both authors separately read interview transcripts, then read a subset together, discussing meaning and key points in each (step 1: familiarization with the data). Authors then separately re-read and coded transcripts using their preferred strategies, Author 1 using Word and notebooks, Author 2 using NVIVO and notebooks (step 2: initial coding). Authors kept a journal throughout the process, reflecting on points in the data, as well as reactions to these and interpretation. After initial coding, authors then discussed how their codes differed and discussed each point of difference until consensus was reached (step 3: themes generated from codes and revised). Themes were written up by Author 2 before being reviewed and revised by Author 1 where appropriate (step 4: writing up and final revision of themes for fidelity with data). Reflexive thematic analysis views researcher’s subjective viewpoints as a benefit, rather than a hindrance, to knowledge generation (Braun & Clarke, 2021 ). Both authors possess unique experiences within LGBTQAP+ and professional structures, with Author 1 identifying as a cis gay man, clinical psychologist, and academic and Author 2 identifying as a cis queer woman and academic. Author 1 has extensive clinical experience supporting the mental health of TGDNB individuals and conducting readiness assessments. As academics, both Authors have a background in LGBTQAP+ related research. The design and interpretation of our results takes a constructivist epistemological approach, acknowledging one’s perception of their reality is influenced by, and constructed with, reference to systems, both social and political, as well as one’s own actions and philosophies. Understanding how researcher’s experiences might be similar or different from study participants was vital to the analytical process and inclusion of insider perspectives was important to support fidelity to participant experience, while outsider perspectives meant no perspective was prioritized. A reflexivity journal was kept by both Author’s throughout the study. Author one’s journal entries reflected on how his professional experiences working with the TGDNB community and conducting assessments may impact interpretation of the results, while Author two’s journal entries reflected on her journey of being queer in Australia and how this may impact interpretation of the results.

Using a mixed-methods approach, we sought to understand Australian HCPs’ (i) processes for administering, (ii) understanding of the purpose of, and (iii) concerns regarding, readiness assessments. These areas of enquiry are discussed below in the context of our findings, the broader literature, and suggestions for the future of readiness assessments. Similar to the findings of Westmacott et al. ( 2024 ), our sample demonstrated broad differences in their assessment processes. Except for a few similarities (e.g. the use of clinical interviews, consideration of dissociative and psychotic experiences, and the importance of clients understanding the risks and benefits of GAMC in determining capacity) participants were not often aligned in the content or approach they believed relevant to each WPATH SoC summary criterion. This inconsistency was also highlighted by the qualitative theme heterogeneity of readiness assessment processes where participants discussed a lack of professional guidance and agreement regarding assessments. These findings support the argument that no standard assessment process exists (e.g. Ashley et al., 2024 ) and help emphasize the general professional uncertainty regarding readiness assessment inclusions (Wi-Hongi et al., 2017 ). This level of heterogeneity signals concern. A main purpose of readiness assessments generated in our data was their role in supporting positive outcomes for GAMC. However, participants survey responses regarding what mental and/or physical health conditions might impact the outcome of treatment (SoC criterion E) were the broadest and most inconsistent in any criterion, with only two of the 29 responses being endorsed by more than two of the 14 qualitative survey participants. This must be considered within the context of participant’s high overall self-ratings regarding their understanding of, and confidence to assess, each criterion, as well as the seemingly extensive professional development and training specifically focused on readiness assessments (up to 100 h for some). Taken together, this appears to indicate that while Australian HCPs believe there are factors that can impact GAMC outcomes and that they explore these in their assessments, they do not agree on what those factors are and believe their understanding of the factors to be correct as evidenced by high understanding and confidence of each criterion. It also suggests that professional development and training in this area is inconsistent in its teaching. These issues undoubtably lead to inconsistencies in client experiences and assessment outcomes, and bring into question the overall validity, reliability, and utility of these assessments. As such, there is a clear need for guidance on readiness assessment processes and content; a desire highlighted by many of our participants. Given the lack of university preparation reported by our participants and elsewhere (e.g. Piñón-O’Connor et al., 2023 ), and echoing calls made by others (e.g. Franks et al., 2023 ), a crucial step is for Australian universities to improve their inclusion of TGDNB healthcare in training programs. A more specific step is, perhaps, the establishment of comprehensive readiness assessment guidelines that outline a minimum standard or list of inclusions. Over half of our participants referenced the need for such guidelines, standardization, and/or specific training and accreditation as valuable. If established from a gender-affirming perspective (including lived-experience consultation), in conjunction with a representative organization (e.g. AusPATH), and with flexibility to ensure assessments are tailored to meet the specific needs and experiences of each client, such guidelines would likely decrease heterogeneity and increase the likelihood that clients will receive the benefits that readiness assessments attest to provide. The primary theme regarding the purpose of readiness assessments was that of informed consent/capacity to consent , with almost all participants highlighting this as a principal purpose. Interestingly, participants often referenced assessments as existing to improve prescriber or surgeon confidence in a client’s capacity as opposed to existing to support a client in their decision making. However, the readiness assessment process as a means of supporting positive GAMC outcomes was also generated as a theme. In this way, participants recognized that certain GAMC considerations (e.g. impacts on fertility) could be explored in a more detailed manner through a readiness assessment compared to via IC, supporting more informed decision-making. This is in line with previous research on client’s experiences where they have felt positive about, or aided by, the process (Holt et al., 2023 ; Obasi et al., 2024 ). There was, however, a strong overall perspective that such opportunities should be optional rather than mandatory, mirroring the perspectives of Westmacott et al. ( 2024 ) sample of Canadian HCPs. Almost all participants saw readiness assessments as protecting against litigation, particularly for prescribers and surgeons. Interestingly, despite this same theme alluding to the notion, participants did not directly report viewing readiness assessments as mitigating regret and possible detransition as has been defined elsewhere (Ashley et al., 2024 ; MacKinnon et al., 2022 ). It may be that participants recognize the rarity of GAMC regret (Bustos et al., 2021 ; Thornton et al., 2024 ) and the lack of evidence that readiness assessments reliably predict or prevent regret (Ashley et al., 2024 ) and thus do not view this as important. Participants reported a range of challenges and concerns with assessments. Like the findings of Budge and Dickey ( 2017 ), the most common concerns related to systematic issues, including requirements being enforced beyond those outlined in the SoC (e.g. multiple assessments). Participants recognized how these further requirements increased the burden of accessing necessary medical care. Of particular note is the frequency with which participants reported personal and professional concerns about working in the field of trans healthcare, especially in the context of political and social forces both locally and overseas. This included concerns regarding personal safety, being the victim of physical violence, as well as professional repercussions. This highlights the need for increased support for HCPs working in this space to maintain their safety and the overall stability of the workforce. The mandatory requirement for assessment prior to certain GAMC, such as gender affirming surgery, was not supported by participants. This is in line with Westmacott et al. ( 2024 ) who found most of their sample of Canadian HCPs did not believe assessments should be mandatory for all clients. Our participants also recognized this as a double standard for TGDNB individuals compared to their cis gender counterparts, as has been widely reported elsewhere in both client (e.g. Budge, 2015 ; Budge & Dickey, 2017 ; Fraser et al., 2021 ) and HCP (Holt et al., 2020 ; Ker et al., 2020 ; Westmacott et al., 2024 ) samples. It seems that when readiness assessments are considered in isolation, our participants recognized their function. However, when considered within the wider model of healthcare decision-making and right to self-determination afforded to all Australian adults, all participants recognized the inequities and social injustice of assessments, leading most participants to view the process as gatekeeping, pathologizing, unfair, and/or unnecessary in its current form. Participants tended to believe in order to truly respect the dignity and rights of TGDNB individuals, readiness assessments should, at a minimum, be made optional in the form of extra support for those who may need or desire this as part of their gender journey. In this way, our sample supported establishing an IC pathway to gender affirming surgery. The IC model grants autonomy, dignity, and decision-making capacity to TGDNB individuals and is indicative of the shift toward patient-centred care, self-determination, and depathologisation in transgender healthcare (Westmacott et al., 2024 ) and is associated with higher satisfaction in overall care compared to other pathways (Spanos et al., 2021 ). Our study was limited by our small sample size. This is unavoidable given the small number of Australian HCPs who conduct readiness assessments. Possible bias also exists in our sample. Given the sociopolitical environment inherent in trans healthcare, as well as our recruitment strategy targeting participants who subscribe to the AusPATH mailing list, it is possible HCPs willing to participate in our study may hold strong views regarding readiness assessments, especially participants who identified as TGDNB themselves. Future investigations may benefit from a broader recruitment strategy. Although not an aim of our study, future investigations may also benefit from recruiting HCPs who request readiness assessments (e.g. surgeons) to understand their perspectives on their purpose and processes.

This research extends empirical understanding of HCPs’ perspectives and processes of readiness assessments for TGDNB individuals prior to GAMC. While our participants recognized possible benefits for some clients, the expectation that all TGDNB individuals should be required to complete a formal assessment prior to accessing GAMC was perceived as gatekeeping, pathologizing, unfair, and/or unnecessary. Our findings support the establishment of an IC pathway to accessing all types of GAMC in Australia, including gender affirming surgeries, and we echo calls of others (e.g. Westmacott et al., 2024 ) that pre-surgical assessments should be optional rather than mandatory. Our findings also suggest there is little consistency in how Australian HCPs administer these assessments. This brings into question their validity, reliability, and utility, making necessary the establishment of general assessment guidelines to improve the experiences of, and outcomes for, TGDNB clients.