All you need to know about medical letters of support for gender affirming surgeries.

Many patients call asking about these mysterious “letters” and want to know what they include. We’ll go over that below.

Letters are dumb. Letters are gatekeeping.
End of article.

I wish.

I wish it was that simple. I wish we could all just acknowledge that they’re tedious, not evidence based, and then wish them away. Unfortunately, as long as insurance companies regulate our American for-profit health system, these letters aren’t going anywhere. In our current system, almost all surgeries require evidence of medical necessity before insurance will cover a portion.

If you desire affirming surgery, then recommending treatment of gender dysphoria with surgery or other affirming procedure is evidence based care. LGBTQI people experience additional health disparities and barriers to healthcare that increase the patient burden in an already broken healthcare system. I know that insurance companies requiring a visit and assessment is a barrier. I know almost all patients would skip a visit for a letter if it was their decision too. I don’t enjoy writing letters either, but I do enjoy helping you get access to care you need.

Letters are not an evidence based practice, but jumping through insurance hoops should be as an affirming experience as possible. Gender affirming care is a medical necessity, and is life saving care, so you deserve access. You don’t need to prove that you are trans or nonbinary, and being trans or nonbinary doesn’t look one way! No one is a perfect surgical candidate, and your healthcare team should be skilled enough to account for any additional difficulties they expect you to encounter during your surgery or recovery.

Before you spend time and energy learning about this process, check the requirements of your insurance company, and your surgeon if you have one. Some insurance companies require no letter, a letter from either a mental health provider or a medical provider or both providers. Not every surgery or surgeon needs a letter from a medical provider, or a mental healthcare provider or a letter at all.

Most insurances and surgeons require letters of readiness that follow World Professional Association for Transgender health (WPATH) standards of care. These letters ensure that you have been diagnosed with gender dysphoria and include additional clinical information.

The information included in the letter can vary based on your individual insurance or surgeon requirements, so it is always wise to familiarize yourself with both. We’ll go over some common information in letters below. You can review this information for your own knowledge, share it with your healthcare team, or use it to prepare for a visit and even write most of your own letter. You are not obligated to write your own letter, and it will still need to be sent and signed by a clinician, but some people feel more affirmed by the process by writing most of their own letter instead of being asked questions by a provider. Insurance companies and surgeons require individual letters for each surgery. For example, if you are planning to pursue affirming top surgery and an affirming hysterectomy, you would need two separate letters.

What is the difference between a Mental Health Provider and Medical Provider Letter?

The difference between a letter from a mental health provider and a medical provider letter are rooted in our specialties and the insurance related guidelines for our letters. Mental health provider letters can be completed by a therapist, counselor, psychiatrist, psychologist, or other mental health professional like a psychiatric nurse practitioner. Mental health letters focus on confirming basic surgery information and understanding, discussing your personal vision, expectations, hopes, insights, anticipation of possible loss and then discussing logistical planning and other practical needs like social supports and healing plan for recovery in addition to a diagnosis of gender dysphoria.

A letter from a medical provider includes the requirements for a mental health provider in addition to detailed information about your medical history. Medical letters are written by your primary care provider, nurse practitioner, or doctor. This differs from a mental health letter because it includes other medical diagnoses you may have, your surgical and medical history and additional medical information. Sometimes surgeons or insurance companies request supporting documents, assessments, or lab work in addition to this letter.

How Long Does an Assessment and Letter Take?

I provide letters for established patients during one 30 minute visit, and I will either read you the letter during that visit or send you a draft immediately after. We will make sure this letter feels true and affirming before I sign and send you an official copy. You will receive a copy within the week for your records and we can also fax it to other providers of your choice. Because these letters require detailed health information and discussion, I do not offer them at an initial establishing care visits. If we are writing more than one letter this typically takes one 30 minute visit for each letter or an extended visit.

I want to say it again — No one is a perfect surgical candidate! That’s okay.

This is where finding the right healthcare team, provider, and surgical resources comes into play. If something makes your surgery or recovery more complex, we simply document how you have prepared or plan to navigate that challenge. You don’t need to hide parts of your health history, promise.

Medical Letters for Gender Affirming Surgery Include:

Date that you established care with that clinic or provider.
When you first remember your sex differing from the sex assigned at birth
Social transition age and details (Hairstyle, name, pronouns)
Legal name changes or plans about doing so (gender marker on identity documents, or decision not to)
Gender affirming hormone therapy start date (This is not a necessity. There is no one way to be, however your letter should include a statement about this decision or medical risks preventing hormone therapy)
Weight, height, BMI
Nicotine use
Substance use history (recreational or illegal substance use, alcohol use patterns)
Previous medical history and chronic conditions: This will also include if they are controlled on current regimens, and how they may affect surgical risk and recovery.
Current medications: Specific drug name, dose, times a day
Previous surgeries
Knowledge of issues with anesthesia
Housing resources, and preparation for post-op recovery (Family, friends, plans for nutrition, or physical therapy or financial support)
Details about how the surgery will affirm your gender identity, decrease gender incongruence, and improve your quality of life. Often this can look like this type of statement:

“ _______ goals of surgery are for her/his/their body to be more in alignment with her/his/their gender and to move through society more safely. Surgery will address her/his/their gender dysphoria by reducing the psychological distress they experience when looking at their body, ( or binding, tucking, or menstruating). It will also improve her/his/their physical safety and reduce the risk of violence due to transphobia.”

Knowledge of the specific surgery and associated risks and benefits of the surgery for you personally.
A formal diagnosis of gender dysphoria and a formal recommendation for surgery and anticipated surgical outcome. This can often look like

“By my independent evaluation of (Your Name), I diagnosed he/she/them with Gender Dysphoria (ICD-10 F64.1). He/she/they has expressed a persistent desire for gender affirming ______________ surgery. I have grossly explained the risks, benefits, and alternatives of this surgery and the surgeon will review these further. I believe the patient has an excellent understanding of them. The patient is capable of making an informed decision about undertaking surgery.”

**You don’t need to prove that you are trans or nonbinary, and being trans or nonbinary doesn’t look one way!**

**Not everyone needs hormone therapy, not everyone needs surgery, and for others surgery is the primary goal.**

Happy to walk with you and help however I can through your gender journey. You are the best person to make decisions about what is best for you. At Spectrum, I recognize that you are the expert on your gender experience and how you can feel most affirmed in your existence. My role is to understand how I can help, educate, support, and get out of the way!

I’ve collected some resources below.

Resources for Mental Health Letters

Gender Affirming Letter Access Project (Free letters from Mental Health providers)
Search for therapists on psychologytoday.com by selecting “Issues” at the top of the screen and selecting “transgender”. Frequently, therapists with closed panels or waitlists will continue to accept patients that are only seeking mental health letters for gender affirming care.

Insurance Support