Getting referred for surgery

On this page you’ll find information about the steps you can take to access transition related surgery. Visit our Introduction to Surgery page for information on what types of surgery you could access.

For some surgeries there are a large number of teams that will offer the surgery in the UK. You can find a complete list of UK surgeons who can be accessed via the NHS on the NGICNS website.

If you have decided to pay for your own surgery, rather than using NHS funding, there are additional options available to you. For more information about these private surgery options read our private surgery page.

You can find useful tips for deciding which surgical team to use on the Umbrella Cymru website.

You can ask clinical staff at your gender clinic about surgery.

You can also book a virtual consultation with one of the Gender Dysphoria National Referral Specialist Service (GDNRSS) Clinical Nurse Advisors who can provide information on:

  • Surgical techniques used by various providers and surgeon teams.
  • Typical recovery times following surgery.
  • Potential post-surgical complications.
  • Surgical eligibility criteria, where providers have these in place.
  • Waiting times for surgical providers.
  • Quitting smoking.
  • Healthy weight loss.

You can contact the service by calling 01522 85 77 99 or by emailing . The service is open Monday to Friday from 9am until 5pm. Find out more about the service.

To get access to most transition related surgeries, you will need a referral from a gender specialist (either via the NHS or privately).

In the referral appointment you’ll discuss:

  • Why you want the particular surgery.
  • What you want the outcome of the surgery to be (for example, do you want to be able to stand to wee?).
  • What your surgical options are.
  • What the surgery involves and potential risks.
  • Your health – including mental health, your BMI, and whether you smoke.

At the end of the appointment, the specialist should tell you whether they will refer you for surgery or not. For some types of surgery, you may need to have appointments with two different specialists at the gender clinic – both of whom will sign your referral letter. In these cases, the second referral appointment is at least 3 months after the first.

Different processes apply for different surgeries if you’re taking the NHS route:

  • Referral letter with one signatory (gender clinic): Mastectomy with chest reconstruction.
  • Referral letter with two signatories (gender clinic): Phalloplasty, metoidioplasty, vulvoplasty, vaginoplasty.
  • Gender clinic might ask your GP to refer you: orchidectomy, hysterectomy

The WPATH Standards of Care state that two signatories are not necessary for surgery referrals and that one ought to be enough. This means that you may be able to access private surgery with one referral signature – ask the surgeon for their requirements.

Find out more on our How To Access Medical Transition page.

Once you’ve had the required number of appointments, the gender clinic will send your referral letter to GDNRSS. They’ll also send a copy to you and your GP.

If you don’t receive confirmation that your referral has been sent, contact GDNRSS to confirm that they have received it.

When they have your referral, GDNRSS will process it and send it to your chosen NHS surgical provider.

GDNRSS have a Single Point of Access support line (call 01522 85 77 99 or email that you can call for information about your referral, the status of your chosen provider and practical information such as travel and parking, who can accompany you, what to take with you, and where to report when you get there.

If you’re having NHS surgery, there will be a wait for your consultation appointment and then for your surgical date.

For mastectomy and chest reconstruction, vulvoplasty or vaginoplasty, you can expect to wait at least a year for your consultation. There is a much longer wait for phalloplasty or metoidioplasty and you ought to prepare yourself to wait at least four years. Read more about the issues with the phalloplasty and metoidioplasty waiting list.

The waiting time for orchidectomy without vulvoplasty or vaginoplasty will depend where you’ve been referred to. This is also true of the waiting time for hysterectomy when accessed without phalloplasty or metoidioplasty. However, you can expect to wait less than a year for these operations in most cases.

If you seek private surgery, waiting times are considerably lower. The amount of time you wait will depend on the availability of the surgeon and on your own availability.

Referrals for surgery are typically valid for 12 to 24 months (depending on the surgeon’s policies). If you’re waiting for longer than that then you’ll be told to ask your gender clinician for a refreshed referral.

Most people’s referrals are accepted without any issues.

However, the most common reasons for someone’s surgical referral being refused are:

  • BMI over the surgeon’s limit. For many surgeons, the required BMI for transition related surgery is 30. This is in line with the NHS service specification for genital surgery.

    For mastectomy and chest reconstruction, the NHS service specification states a maximum BMI of 40.

    Some private surgeons may have a higher BMI requirement, but this is typically 40 at the highest.

    There is an NHS tool to help you calculate your BMI.

  • Mental health. If you have ongoing mental health difficulties, that is not in itself a reason for your referral to be refused. However, if the gender clinic clinician or surgeon feel that your mental health difficulties not being well managed, they might refuse the referral.

  • Health conditions. If they believe that surgery would place you at a high risk due to a health condition, a surgeon might refuse to accept your referral.

  • Haven’t been on hormones long enough. If you don’t take hormones and don’t plan to, your referral isn’t likely to be rejected because of it.

    Hormone therapy will result in lots of changes to your body, including to your chest and genitals. That’s why some surgeons have certain requirements for people who are taking (or planning to take) hormones.

    For mastectomy and chest reconstruction, surgeons like you to have been on testosterone for 6 to 12 months (it varies depending on the surgeon). The NHS service specification does not specify a minimum amount of time.

    For genital surgery, the NHS service specification states that a person should have been on hormone therapy for at least a year. Private providers may have different requirements, as WPATH’s Standards of Care recommend that a person should have been on hormone therapy for at least 6 months.

If you’re an older person, you may be pleased to hear that old age in itself is not a reason to refuse referral. However, if you have health conditions, they might be.

It is important to note that most people’s referrals are not refused. However, this section gives you information on what you can do if you’re one of the few people who are refused a surgical referral.

Find out why

The first thing to do is ask why your referral was refused. If it is something that can be addressed – for example, quitting smoking – then ask your gender clinic for support to take any necessary steps. You can then seek re-referral when you’re ready to.

Ask for a second opinion

If you aren’t happy with the refusal for the referral, you can seek a second opinion. If the gender clinician refused to refer you, ask for an appointment with someone else. If the surgeon refused your referral, ask your gender clinic to refer you to another surgical team (if available).

Know your rights

If your disability or chronic illness are given as a reason for the referral refusal, ask for more information. If the reason is based on assumptions about you and your body, rather than in genuine medical risk, it may be a breach of the Equality Act (2010).

The Equality Act (2010) protects people under the ‘disability’ characteristic if they have a physical or mental impairment that has a substantial, adverse, and long-term effect on their ability to carry out normal day-to-day activities. It is against the law to discriminate against someone because of this. If you are worried that you’ve experienced disability discrimination, seek legal advice.

Read more about disability discrimination

If you either can’t or don’t want to take hormone therapy, this should not stop you from accessing transition related surgery.

Surgeries for trans men and some non-binary people

Neither the NHS service specification or the WPATH Standard of Care specify that mastectomy has to come before phalloplasty or metoidioplasty. There is no requirement for a person having phalloplasty or metoidioplasty to have had a mastectomy.

It is possible to have a phalloplasty or metoidioplasty without having a vaginectomy. However, retaining a vagina might prevent someone from having the urethral lengthening procedure needed if you want to wee standing up. This is something you can discuss with your surgeon if it is relevant to you.

Hysterectomy is only an essential part of phalloplasty or metoidioplasty if you wish to have a vaginectomy. If a person wants to retain their vagina, they would not need a hysterectomy. This is something you can discuss with your surgeon if it is relevant to you.

Surgeries for trans women and some non-binary people

An orchidectomy is an essential part of a vaginoplasty or vulvoplasty – these procedures involve removing a person’s testicles and reusing the skin from their scrotum.

Orchidectomy without any additional procedures is available on the NHS, ask your gender clinic what your options are.

It is possible to have a penectomy without a vaginoplasty or vulvoplasty, but this is not offered on the NHS. A penectomy in combination with an orchidectomy is referred to as ‘genital nullification’.

Smoking can impact your surgical outcomes, so some gender clinics expect you to have quit smoking prior to your referral. Most surgeons will require you to have not smoked for several weeks or months before surgery.

The NHS service specification suggests that people should stop smoking for at least 6 weeks before and 6 weeks after their surgical date.

There is information about quitting smoking on the NHS website, where you can create a ‘quit plan’.

The NHS has a weight loss page with information on tools you can use to lose weight healthily. You can also ask your GP for support, they might be able to refer you to a local service.

Sometimes there is a specific reason for people being unable to lose weight – for example, because of certain disabilities. If this is the case for you, some surgeons might be willing to be a bit more flexible.

An important acknowledgement

At TransActual, we know all too well about the challenges associated with living with dysphoria, navigating NHS transition related care and living as a trans person in a transphobic world. We also know that this has a direct impact on people’s mental health, which in turn impacts whether we smoke and our eating and exercise habits.

It is also important to note that BMI is an unreliable measure of obesity and that disabled and/or Black and brown people can often be disproportionately be impacted by NHS BMI requirements.

We’re working for change within the system of NHS transition related care and will continue to raise these issues with the NHS.

You can ask your gender clinic for mental health support. Some NHS clinics offer counselling.

For information about trans specific and trans inclusive mental health support services, take a look at TransActual’s Sources of Support page and on our Mental Health and Wellbeing hub.

You’ll also find more information about counselling on

If you change your mind about which team you’d like surgery with, that’s ok. It will create a bit more admin and possibly mean that you have to wait a bit longer. However, it’s important to make the decision that is right for you.

Changing NHS surgical team

If you’re waiting for surgery on the NHS, contact GDNRSS (call 01522 85 77 99 or email who will tell you what you need to do.

It is important to note that you are likely to be treated the same as someone who had only just been referred for surgery. This means that you might end up waiting longer than you otherwise would have.

Moving from an NHS waiting list to a private waiting list

Some people change their mind about waiting for NHS surgery and decide to go private. Sometimes they decide to have surgery privately with the surgeon they’d been referred to for NHS care. Other people might decide they’d prefer a different surgeon.

If you want to swap from an NHS waiting list to a private one, contact the surgeon via their private clinic’s e-mail address (it’ll be one that doesn’t have NHS in it). Ask them what they need from you in terms of referral.

After you’ve had surgery privately, contact GDNRSS to let them know that they can take you off the waiting list for that specific surgery type.

Changing private surgical team

If you’re having surgery privately, just let the private team know that you don’t want to be on their list any more. You can then contact the other private team and ask if they can accept your original referral letter, or whether you will need to provide a new one.

GDNRSS have produced detailed guides about gender surgeries, which you’ll find on the Introduction to Surgery page

Other sources of information include:

Errors or omissions

Is there something missing from this page? Have you spotted something that isn’t correct? E-mail to let us know.

A disclaimer: TransActual do not provide medical, health, or legal advice. The content of this page is intended for information purposes only. It is not a substitute for medical advice, diagnosis or treatment from a medical professional. It is not a substitute for advice from a legal professional. We strongly suggest you consult a healthcare professional or legal professional for specific advice about your situation. TransActual do not advocate or recommend the purchase of any specific product and we do not endorse or guarantee the credentials or appropriateness of any health care provider, any product or any provider of insurance and legal services.

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