Health Care Department Operations Manual

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Chapter 1 – Health Care Governance and Administration

Article 2 – Health Care Program Governance

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1.2.16 Gender Affirming Surgery Review Committee

  • Policy

    • California Correctional Health Care Services (CCHCS) patients may request gender affirming surgery (GAS) or revisions to GAS, pursuant to the California Code of Regulations Title 15, Section 3999.200. Patient requests for GAS, including revisions to GAS shall be referred by the institution to the Gender Affirming Surgery Review Committee (GASRC).

  • Procedure

    • Institution Referral Process

      • Patient Request for GAS or Revisions to GAS

        • A patient may request GAS or revisions to GAS (excluding complications that need timely follow up by a surgeon) by completing a CDCR 7362, Health Care Services Request Form or by verbally informing their primary care provider (PCP).

        • When a patient submits a CDCR 7362, a PCP appointment shall be scheduled pursuant to the Health Care Department Operations Manual (HCDOM), Section 3.1.5, Scheduling and Access to Care, to review the form.

      • Primary Care Provider

        • The PCP shall submit an electronic order for “Request for GAS Review Committee” at the time of the initial visit, and the Electronic Health Record System (EHRS) will generate a “MH GAS Evaluation Initial” order upon placement.

        • If, during the initial PCP visit, a Gender Dysphoria (GD) diagnosis is not currently established by a mental health (MH) clinician, the PCP shall order a “Mental Health Gender Dysphoria Diagnostic Evaluation.”

      • Mental Health Staff

        • When a “Mental Health Gender Dysphoria Diagnostic Evaluation” is ordered, the MH Evaluator shall complete and submit the “Mental Health Gender Dysphoria Diagnostic Criteria” PowerForm within 14 calendar days.

        • MH staff who author MH GAS Evaluations are required to complete the associated statewide training.

        • When a “MH GAS Evaluation Initial” order is generated, the MH Evaluator shall:

          • See the patient within 45 calendar days from the date of submission of the electronic order for “Request for GAS Review Committee.”  If needed, subsequent “MH GAS Evaluation Follow Up” visits may be ordered and completed within seven calendar days of order entry.

          • Complete and submit the “MH Gender Affirming Surgery (GAS) Evaluation” PowerForm within 90 calendar days from the date of submission of the electronic order for “Request for GAS Review Committee.”

      • Utilization Management Registered Nurse

        • The Utilization Management Registered Nurse (UMRN) shall complete and submit the “CDCR 7466 Gender Affirming Surgery Request Checklist” PowerForm within 14 calendar days from the completion date of the “MH Gender Affirming Surgery (GAS) Evaluation” PowerForm.

    • GASRC Membership

      • Co-Chairpersons

        • The Co-Chairpersons shall:

          • Be appointed by the Deputy Director, (DD), Medical Services, and the DD, Statewide Mental Health Program.

          • Consist of a minimum of one Deputy Medical Executive (DME), Assistant DME, Chief Medical Executive (CME), or Chief Physician and Surgeon (CP&S); and a minimum of one Mental Health Assistant DD, Chief Psychologist, or Chief Psychiatrist.

          • Be non-voting members, unless needed to reach a quorum as noted below.

          • Designate a voting member to chair the GASRC in their absence.

        • There must be at least one Co-Chairperson, or designee, present at each GASRC meeting.

      • Voting members

        • Voting members (and alternate designees) shall be appointed by the DD, Medical Services, and the DD, Statewide Mental Health Program, and shall consist of:

        • A minimum of three physicians or advanced practice providers (APPs) from Medical Services, at least one of which must be a physician;

        • A minimum of three psychiatrists from the Statewide Mental Health Program; and

        • A minimum of three psychologists, licensed clinical social workers (LCSWs), licensed marriage and family therapists (LMFTs), or licensed professional clinical counselors (LPCCs) from the Statewide Mental Health Program.

      • Training

        • Mandatory standardized training requirements approved by the GASRC shall be completed prior to serving as a committee Co-Chairperson or voting member for the GASRC.

    • GASRC Meetings

      • A quorum for purposes of voting shall include at least one voting psychologist, LCSW, LMFT, or LPCC, one voting psychiatrist, and one voting physician or APP from Medical Services. In reaching the quorum requirement, the Co-Chairpersons may serve as a member for their clinical discipline, if necessary, to reach the GASRC quorum.

      • Non-voting participants may include the author of the MH evaluation (or designated MH clinician), the PCP or a provider familiar with the patient’s physical health, and, if deemed appropriate for the discussion by the Co-Chairpersons:

        • Institution medical, MH, or nursing leadership.

        • Warden or designee.

        • The patient’s care team, including medical, MH, or nursing.

        • Nursing representation from headquarters including, but not limited to, the Statewide Chief Nurse Executive or designee.

        • Other pertinent CCHCS or CDCR staff.

      • The GASRC shall be scheduled to meet weekly unless there are no requests for the committee to consider.

    • GASRC Conflict of Interest

      • A committee member shall not participate in the committee deliberation or vote on a case being reviewed if the member:

        • Was a designated provider in the current GASRC evaluation or review, or

        • Was the MH Evaluator, or

        • Has provided longitudinal care for the patient in the past 12 months.

      • When a member has a conflict, the member shall:

        • Not deliberate or vote on the case, but they may still present information to the committee and be available for questions.

        • Self-identify a potential conflict and voluntarily notify the committee Co-Chairpersons and recuse themselves for that case(s).

    • GASRC Scope of Review

      • Submissions for GAS shall be considered by the GASRC in the order in which they are received, absent extenuating circumstances approved by the Co-Chairpersons.

      • For GASRC submissions that include more than one requested surgical procedure, each surgical procedure request shall be considered separately.

      • The GASRC shall review cases within 90 calendar days from date of submission of the “CDCR 7466 Gender Affirming Surgery Request Checklist” PowerForm, absent extenuating circumstances.

      • The GASRC shall review, evaluate, and discuss the information provided by the institution (and the patient, if applicable) and obtain additional information as deemed necessary.

      • If the GASRC deems additional information is required prior to making a final decision, the GASRC review shall be deferred until the additional information is collected.

      • If the GASRC requires additional information from a surgeon who specializes in GAS, the patient shall be scheduled for a consultation with the patient’s care team and the GASRC review deferred until such time that the consultation notes are available in the EHRS.

      • The following shall be considered by the GASRC when reviewing a GAS request, if applicable based on the current version of the World Professional Association for Transgender Health Standards of Care and the type of surgery requested:

        • If a diagnosis of GD is supported with appropriate documentation and clinical justification.

        • Any known medical or MH contraindications to surgery or conditions that may impact surgical recovery have been fully assessed and well-controlled for an appropriate amount of time specific to the patient.

        • The level of distress related to GD demonstrated by the patient. The GASRC shall:

          • Review all relevant documents and determine whether the patient’s GD symptoms are primarily due to environmental factors, mental illness, or any other factor.

          • Consider whether available treatments other than GAS could improve or alleviate the patient’s GD symptoms.

        • If there is evidence suggestive of any external coercion or predation.

        • If evidence exists that suggests the patient does not have the ability to successfully and safely transfer and adjust medically and psychologically to their new environment postoperatively including the ability to follow medical or MH advice.

        • If applicable to the GAS requested, whether the:

          • Patient received 6 to 12 continuous months of medically supervised gender affirming hormone therapy (GAHT) appropriate to their gender embodiment goals (unless they have a medical contraindication, are unable or do not desire to take hormones, or their gender embodiment goals do not include the use of GAHT).

          • Patient’s hormone levels meet the minimum requirements for the requested procedure (unless they have a medical contraindication, are unable or do not desire to take hormones, or their gender embodiment goals do not include hormone levels at a specific minimum threshold/range).

        • If applicable to gonadectomy, whether there is documentation in the EHRS to reflect discussions and understanding by the patient that the procedure will result in complete loss of fertility.

        • Any other information available that may be relevant to the discussion or determination.

    • GASRC Decisions

      • The decisions of the committee shall be based on the following:

        • When a quorum of less than six voting members results in a unanimous vote, the decision will stand.

        • When a quorum of less than six voting members results in a split vote, the case shall be brought back to a larger committee consisting of at least two representatives from each aforementioned discipline (excluding the Chairperson), whereby a decision will be based on a majority vote.

        • In the event of a tie, the Chairperson has the option to request additional information and review the case at future GASRC meetings or serve as the tiebreaker if no additional information is needed or available.

      • The Chairpersons may postpone any GASRC meeting to request additional information and review the case at future GASRC meetings.

      • If additional information is obtained after the GASRC has issued an approval but before the completion of surgery, the GASRC may reconsider the approval if deemed necessary. The committee may determine that a rescission of a former approval is warranted.

      • Once the GASRC has made a decision (approval, non-approval, or rescission of former approval), a memorandum shall be completed conveying the decision, the factors considered in the decision based on the criteria noted in Section (b)(5)(G) above, and any specific information that the GASRC determines would be helpful to the patient and their care team to understand the decision. The decision memorandum shall be addressed to the CME, and copies shall be provided to the following:

        • Patient

        • CP&S

        • Chief of Mental Health

        • Chief of Psychiatry

        • Chief Nursing Executive

        • PCP

        • Mental Health Primary Clinician, if applicable

        • Mental Health Primary Psychiatrist, if applicable

        • UMRN

        • Designees from Health Care Invoicing and Direct Care Contracts applicable only to approvals or rescissions

      • GASRC support staff shall distribute the decision memorandum to the CME via email within seven calendar days from the GASRC decision, absent extenuating circumstances.

      • The GASRC decision shall be entered into the EHRS by a committee Co-Chairperson or designee.

      • Patients who are approved for GAS shall be scheduled:

        • With an MH clinician to discuss the findings of the GASRC within 14 calendar days of the decision entry in the EHRS. A copy of the GASRC decision memorandum shall be provided to the patient at that time.

        • For an initial visit with the surgeon, when an approval is entered into the EHRS.

      • Patients who are not approved for GAS, or who have had their former approval rescinded:

        • Shall be scheduled separately with an MH clinician and PCP to discuss the findings of the GASRC within 14 calendar days of decision entry in the EHRS. A copy of the GASRC decision memorandum shall be provided to the patient at the MH appointment.

        • May submit a new request for the same GAS no sooner than one year after the date of the last issued GASRC decision memorandum, unless new information is provided that was not previously considered at the time the GASRC reviewed the case and rendered a decision.

        • May submit information regarding a particular GAS request, that was not previously available at the time of the most recent GASRC review, only through the process under Section (b)(1).

        • May grieve any GASRC decision without submitting information that was not previously available at the time of the GASRC review, only through the health care grievance process set forth in the HCDOM, Section 5.1.7, Health Care Grievance.

      • The GASRC support staff shall scan the GASRC decision memorandum and documents considered in making the decision into the EHRS within seven calendar days of receipt of the signed GASRC decision memorandum.

    • Record and Information Requests related to Gender Affirming Care or Services

      • Any court order, administrative order, or subpoena requesting medical records related to gender affirming health care shall be processed by Health Information Management in accordance with the HCDOM, Section 2.3.4, Release of Protected Health Information.

      • Refer to the HCDOM, Section 4.1.7, Gender Dysphoria Management, for information regarding the disclosure of gender affirming related medical information to an individual, agency, or department from another state, or to a federal law enforcement agency.

  • References

    • California Civil Code, Division 1, Part 2.6, Chapter 2, Section 56.109

    • California Code of Regulations Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200

    • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 6, Article 12, Section 62080.14, Transgender or Intersex Inmates

    • Health Care Department Operations Manual, Chapter 2, Article 3, Section 2.3.4, Release of Protected Health Information

    • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.5, Scheduling and Access to Care

    • Health Care Department Operations Manual, Chapter 4, Article 1, Section 4.1.7, Gender Dysphoria Management

    • Health Care Department Operations Manual, Chapter 5, Article 1, Section 5.1.7, Health Care Grievance

    • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision, 2022

    • World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transgender and Gender Diverse People, Version Eight (8), 2022

  • Policy Control
    Executive Sponsors: Deputy Directors, Medical Services and the Statewide Mental Health Program
    Effective: 07/21/2021
    Revised: 6/30/2023, 10/09/2024, 6/10/2026