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A4TE's Trans Health Project

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  • Current: Minor Surgery Checklist

Minor 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.


Download PDF

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
  • Harms associated with not having or delaying surgery
    • 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 diversity/incongruence is marked and sustained over time
    • Meets the diagnostic criteria of gender incongruence in situations where a diagnosis is necessary to access health care
    • Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment
    • Mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed; sufficiently so that gender-affirming medical treatment can be provided optimally.
    • Informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility
    • At least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment 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 seen this surgery help other trans patients, note that
  • If there has been involvement of parent(s)/guardian(s) in the assessment process, note that, unless their involvement is determined to be harmful to the adolescent or not feasible

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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