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  • Current: Adult Surgery Checklist

Adult Surgery Checklist

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.


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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

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

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Updated on Mar 12, 2025

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