Why Letters of Support Cost Money and How My Practice Is Different
If you have ever needed a letter of support for gender-affirming medical care, you may have wondered why it costs money. You may have also encountered messaging online that frames paid letters as unethical, unnecessary, or gatekeeping.
Those concerns come from a very real and painful history. They also deserve a more honest and transparent explanation.
This post is about clarity, not justification. It is about explaining how and why this work exists in my practice, where the money actually goes, and how paid letters can be ethical, affirming, and access-oriented when done correctly.
A Brief Acknowledgment of the History
Letters of support have a complicated and often harmful history.
For decades, transgender and gender-diverse people were forced to prove their identities to medical and mental health providers in order to access care. Letters were frequently used to exploit the community, police gender expression, delay care, or deny treatment altogether. Many people were required to perform certainty, stability, or conformity in order to be deemed “eligible.”
That history matters. It is valid to feel frustrated, angry, or mistrustful of letter requirements.
At the same time, letters still exist within current medical and insurance systems. They are often required by surgeons, hospitals, and insurers regardless of how outdated or flawed those requirements may be.
My role is not to defend the system. My role is to help people navigate it with as little harm and as much support as possible.
Why Letters Still Exist in 2026
Most letter requirements are tied to insurance policies, surgeon protocols, and institutional risk management. They are not measures of identity validity.
Letters typically document:
Capacity for informed consent
Understanding of risks, benefits, and alternatives
Readiness for the specific procedure
Stability of any co-occurring mental health concerns
Compliance with surgeon or insurer requirements
They exist because systems demand documentation, not because your identity needs approval.
A well-written letter can reduce barriers, prevent delays, and help surgical teams feel confident moving forward. The goal is to smooth the path, not slow it down.
Why My Practice Charges for Letters
Transparency matters, so here it is plainly.
Letters of support are clinical work. They require time, expertise, documentation, and legal and ethical responsibility.
When you pay for a letter through my practice, you are paying for:
A comprehensive assessment aligned with current standards of care
Accurate documentation that meets surgeon and insurance requirements
Time spent writing, reviewing, and coordinating care
This is not just a signature. It is a clinical service.
Where the Money Actually Goes
Fees from letters of support with my practice do not disappear into a void.
They help cover the real costs of running an affirming, independent practice, including:
A secure electronic medical record system
HIPAA-compliant communication tools
Licensing fees across multiple states
Continuing education and specialized training
Professional liability insurance
Administrative time and infrastructure
These expenses are what allow me to keep my practice accessible, virtual, and focused entirely on gender-affirming care.
My practice is queer-led and run, so expenses also go toward the community. I also need to support myself so money goes directly to helping me support myself as this is my job.
This Is Not Supplemental Income. It Is the Foundation of My Practice
Many clinics offer letters as an occasional or supplemental service. My practice was built specifically to provide gender-affirming care, including assessments and letters of support. This work is not an add-on. It is the core of what I do.
Because letters are foundational rather than incidental, there is an associated cost that reflects the time, responsibility, and infrastructure required to do this work ethically and sustainably. This structure allows me to focus availability on people actively seeking gender-affirming care, avoid unnecessary ongoing therapy requirements, reduce gatekeeping by offering clear and efficient assessments, and write letters that meet requirements the first time. The goal is not volume. The goal is access with integrity.
Charging for letters does not mean you need to prove your identity, perform certainty or perfection, or engage in long-term therapy if not deemed clinically necessary. Your care is not conditional on compliance or conformity. My role is not to decide who is “trans enough.”
My role is to help you meet external requirements while protecting your autonomy and well-being.
Letters Can Be Supportive, Not Just Bureaucratic
While letters are often experienced as annoying or stressful, the appointment itself can be genuinely helpful. Many people share they’ve found it useful to talk through fears, expectations, and timelines, prepare emotionally for surgery or hormones, identify supports for recovery, discuss what happens if dysphoria shifts or intensifies, what they can do if there are complications, and build confidence in decision-making.
The assessment is not about convincing you or questioning you. It is about supporting you through a meaningful and life changing event.
A Final Thought
It is reasonable to wish letters were not required at all. It is also reasonable to want those requirements handled with care, respect, and transparency while they still exist.
Charging for letters is not inherently gatekeeping. The harm comes from how the process is done, not whether it is compensated.
My goal is to reduce barriers, not create them. To be clear, efficient, affirming, and honest. And to help you access the care you deserve with as little friction as possible.
If you are navigating gender-affirming medical care and need a letter of support, you deserve a process that treats you with dignity, not suspicion.
