Great points. Gender reassignment surgery has been available for much longer than 20 years. And while surgeons themselves might not gatekeep GRS by requiring counseling, there's no way to get GRS approved for payment through any insurance company, public or private, without requisite mental health care first. Perhaps the author is speaking of surgeons who work with wealthy patients who pay independently, but I can't imagine that's a significant phenomenon. You would have to be very rich indeed in the United States to be able to go through GRS entirely out of pocket. Surgeons' fees aside, hospital fees and anesthetist fees would normally run over $100,000, and probably much more.