Beyond the Checklist — A Position Paper on Patient Selection in Gender-Affirming Laryngology

As a response to some recent national decisions let’s think more clearly: Beyond the Checklist: Clinical Judgment, Patient Narrative, and the Surgeon’s Responsibility in Gender-Affirming Laryngology. We can do better.

The frameworks still used to select patients for gender-affirming surgery descend from standards written decades ago, when outcomes data were thin and social acceptance was limited. They imposed algorithmic gatekeeping—mandatory psychiatric evaluation, documented “real-life experience,” staged approvals—that was meant to protect patients but in practice erected barriers that were neither evidence-based nor evenly applied. Drawing on more than three decades of my gender-affirming voice treatment along with the development of Feminization Laryngoplasty, I believe that structured clinical assessment—centered on the patient’s narrative, commitment history, and where appropriate family engagement—identifies good surgical candidates more reliably than the old prerequisites did. Laryngology is positioned to offer an evidence-informed, surgeon-accountable model of patient selection that resists both the gatekeeping failures of the past and the politically motivated restrictions of the present.

Let’s think about the hard parts of this argument: the honest range of surgical outcomes, the surgeon’s obligation to account for failure, and why a categorical age threshold is a poor substitute for clinical judgment.

Read the full paper here: Beyond the Checklist →