What Should Be Included in a Letter of Support for Gender Affirming Surgery? A Guide for Patients
Introduction
If you are preparing for gender affirming surgery, you have probably been told you need a letter of support from a mental health provider. This requirement can feel confusing, frustrating, or even invasive, especially when you already know who you are and what you need.
A strong, affirming letter is not meant to gatekeep your care. It is meant to document your readiness, support your access to surgery, and provide the information your surgeon and insurance company require. When done well, it protects your autonomy and helps your medical team move forward with confidence.
Here is what a high quality, ethically written letter includes and why each element matters.
1. A Clear Statement of Purpose
Every letter begins by stating exactly what it is for, which procedure it supports, and that it aligns with WPATH Standards of Care Version 8. Example: “This letter documents that the patient has been evaluated for readiness for gender affirming top surgery in accordance with WPATH SOC8.”
This eliminates confusion and helps your surgical team process it quickly.
2. Provider Credentials and Expertise
A strong letter explains the provider’s background, including experience with:
Transgender and non-binary healthcare
Gender affirming care
LGBTQ+ mental health
Any relevant trainings or specializations
This helps surgeons and insurance reviewers understand that the assessment comes from someone qualified and knowledgeable.
3. Your Identity and Demographic Information
The letter includes:
Your legal name, affirmed name, and pronouns
Your gender identity
Your date of evaluation
Your provider’s identifying information
This ensures clarity and accuracy throughout your medical record.
4. Documentation of Gender Dysphoria When Required
Many surgeons and insurance companies still require diagnostic language and a diagnosis code be included in the letter (Gender Dysphoria of Adulthood F64.0). A respectful letter will document that you meet criteria for Gender Dysphoria without questioning your identity.
This step is about meeting administrative requirements, not legitimizing who you are.
5. Confirmation of Gender Affirming Hormone Therapy (When Required)
For certain surgeries, letters must document that you have been on gender affirming hormone therapy for at least one year (some insurances companies now require 2 depending on the procedure you are pursuing), unless medically contraindicated or not desired.
This is not true for all procedures, but when it is required, it must be clearly stated.
6. Documentation of Living in a Gender Role Congruent With Your Gender Identity (When Required)
Some surgeons and insurance companies still expect documentation that you have, “lived in a gender role aligned with your gender identity for at least one year”.
Not all patients want or need to socially transition in the same way. When this information is required, it is included respectfully and without pathologizing the individual or forcing them to take steps that are not aligned with their goals or affirming.
7. Confirmation of Informed Consent and Decision Making
A strong letter states that you:
Understand the benefits and risks of surgery
Symptoms are persistent in nature and the procedure is medically necessary
Know the potential outcomes, both positive and challenging
Understand the permanent nature of the procedure
Acknowledge any risks associated with fertility and sexual health
Understand the expected recovery timeline and care requirements
Are able to give informed consent and make medical decisions for yourself
The surgery is “current, well thought out, not impulsive, and not due to any other treatable mental disorder other than gender dysphoria.”
8. Mental Health and Medical Stability
The letter includes a brief clinical summary confirming that:
Any mental health conditions are reasonably well controlled (past or present)
You are able to follow postoperative instructions
You do not have untreated psychosis or another condition that would prevent you from consenting to care or being able to care for yourself safely post op
You are not currently using tobacco or cannabis and/or are willing to discontinue prior to surgery
No other substance use or risk is of concern
Surgeons will often tell you the specific timeline for stopping tobacco, nicotine, vaping, or cannabis prior to surgery, but letters often need to confirm that you can successfully participate in your own recovery plan.
9. Your Support System and Recovery Plan
Most surgical teams want to know that you have:
A support person to be with you pre and post op
A plan for where you will recover
Adequate resources and preparation for the healing period
This helps ensure your safety after the procedure.
10. A Direct, Unambiguous Recommendation
A good letter ends with a clear statement such as: “I recommend and refer this patient for gender affirming surgery.”
It should be direct and free of vague or hesitant language.
Why These Requirements Exist
Many of these elements come from insurance policies, surgeon requirements, and safety considerations. They are also connected to a long and painful history where transgender people were pathologized, mistrusted, and forced to “prove” their identity to access basic healthcare.
These letters grew out of systems that treated transgender people as incapable of knowing themselves. They were designed to act as a gatekeeper, not a support.
You are right if this process feels invasive, unnecessary, or outdated. It often is.
Even though the field is moving toward informed consent and autonomy, many of these older requirements still exist in medical and insurance systems. Until those structures change, letters often need to include specific language so your care is not delayed or denied.
A well written letter works within those systems while also respecting you as a whole person. It should:
Support your access to care
Reduce barriers instead of adding new ones
Provide accurate documentation that surgeons and insurers need
Help your medical team move forward quickly and confidently
How Therapy Can Still Help After Surgery
Even though the requirement for a letter may feel outdated or unnecessary, the therapy itself does not have to be. Many people find that having support before and after surgery makes the entire experience smoother, less overwhelming, and more grounded.
Surgery is a major physical and emotional transition. Even when it is deeply wanted and affirming, it can bring up strong feelings, unexpected challenges, or moments of doubt. Sometimes removing one area of dysphoria can make another area feel louder. That does not mean surgery was the wrong choice. It simply means your brain and body are adjusting.
Post-op emotions can include relief, excitement, frustration, grief, impatience, or a strange sense of “now what.” None of this means you made a mistake. Healing is work, and it is normal for it to be hard, boring, slow, or uncomfortable at times.
Therapy can help you:
Navigate the emotional ups and downs of recovery
Separate temporary frustration from long-term dissatisfaction
Build confidence in your healing process
Process changes in body image or identity
Adjust to new routines and physical sensations
Prepare for setbacks or complications without panic
Create a backup plan and support network if something unexpected happens
The surgery itself happens while you are asleep. The real work is in the healing. Having a therapist during this period gives you a place to land, talk through fears, celebrate milestones, and stay connected to your long-term goals.
Therapy does not exist to gatekeep your identity. It exists to support you through one of the most significant and vulnerable transitions of your life.
If You Need a Letter of Support
The goal is to open the door for you, not close it. My approach is to honor the reality of the system while doing everything possible to ensure you receive the care you need without unnecessary obstacles.
My practice provides respectful, efficient, and non-gatekeepy letters for transgender and non-binary adults seeking gender affirming care. I follow WPATH SOC8 requirements while prioritizing your autonomy, safety, and dignity.
If you are preparing for surgery and need support, you can learn more or request an appointment below.
