Use this checklist to ensure that each element is included in your letter. Use language that is client specific; do not simply copy this checklist.
Identification of the procedure and diagnosis
- The client’s general identifying characteristics (age, gender, etc.)
- The duration of the provider’s relationship with the patient
- That the patient has gender dysphoria
- Procedure needed
Procedure-Specific Dysphoria & Related Complaints
- Include a narrative of gender dysphoria symptoms generally, and those that specifically relate to the procedure in question.
- Any complaints of how gender dysphoria impedes their ability to perform activities of daily life
- Any steps they have taken to alleviate gender dysphoria such as chest binding, makeup, wigs, prosthetics, etc.
- Harms associated with not having or delaying surgery
- Example: Breast Augmentation
- That the patient has had insufficient breast growth to alleviate their gender dysphoria
- Any complaints that the patient has stated about the size and shape of their current breasts, misgendering, clothing, etc.
- If breasts are atypical for a female, describe, e.g., size, Tanner stage, more like male gynecomastia (breast mass concentrated closer to the nipple);
- Reference to size of the torso if the breasts are disproportionately small compared to their overall body
- Example: Facial Surgery
- Discussion of the distress that is caused by having male facial features
- Examples of being misgendered because of their face
- Examples of limitations/impairment related to face dysphoria (anxiety in public, street harassment, employment discrimination, intimate relationships, etc.) caused by their face
- Any steps the patient has taken to cope such as make up, headbands, wigs, hats, hairstyles, etc. and how that is insufficient
- Example: Facial Hair Removal
- Dysphoria specifically related to facial hair
- Using makeup to hide beard shadow
- Describe specific examples of impairment due to facial hair (how they are limited presently socially, school, physically, etc.)
- Example: Top surgery
- Chest dysphoria
- Binding, problems associated with binding
- Long-standing desire for surgery
- Example: Breast Augmentation
Statement of medical necessity
- Explain that WPATH criteria for surgery have been met. (p. S258, Appendix D of WPATH SOC v8, available here) Address each point of the WPATH Criteria:
- Gender incongruence is marked and sustained
- Meets diagnostic criteria for gender incongruence prior to gender-affirming surgical intervention in regions where a diagnosis is necessary to access health care
- Demonstrates capacity to consent for the specific gender-affirming surgical intervention
- Understands the effect of gender-affirming surgical intervention on reproduction and they have explored reproductive options
- Other possible causes of apparent gender incongruence have been identified and excluded
- Mental health and physical conditions that could negatively impact the outcome of gender-affirming surgical intervention have been assessed, with risks and benefits have been discussed
- Stable on their gender affirming hormonal treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated)
- Indicate you recommend surgery
- Use the phrase “medically necessary,” which is generally defined in insurance policies simply to mean clinically appropriate care to treat a condition in accordance with generally recognized standards of care
- Indicate if the surgery is undertaken for the purpose of treating gender dysphoria and will help to alleviate the person’s gender dysphoria
- If you have liaised with professionals from different disciplines within the field of trans health for consultation and referral, note that
- If you have seen this surgery help other trans patients, note that
State the qualifications of the provider
Discuss your credentials as applicable. Omit things that do not apply.- Education and degree
- Licensure
- Length of time & experience working with/diagnosing trans patients
- Number/percentage of trans patients seen, if a significant part of your practice
- Continuing education in the assessment and treatment of gender dysphoria;
- Relevant professional associations
- Relevant publications
- Relevant trainings given, courses taught
- Consider attaching CV if a specialist
If you need any additional information, please do not hesitate to contact me at [phone].
Sincerely,
Signature Provider’s Name Licensing information
Updated on Mar 12, 2025