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 (per WPATH SOC p. 28)
- The duration of the provider’s relationship with the patient
- That the patient has gender dysphoria
- Procedure needed
Hormone use
- What hormone therapy the patient is on
- Date started and length of time on hormones
- That the patient takes the hormones consistently and appropriately
- Limits of hormones on ability to change facial features
- That hormone therapy has been insufficient to change the shape of her face to alleviate gender dysphoria
Face dysphoria
- Any complaints that the patient has stated about her face or misgendering
- Describe facial features that are typically male
- Surgeon: describe how the specific procedures will change those features from male to female
Capacity to make a fully informed decision and to consent for treatment
- Patient has capacity to make a fully informed decision
- Patient has provided informed consent for surgery (if you have discussed it with them)
Statement of medical necessity
- Indicate if you recommend surgery
- If you find it to be accurate, use the phrase “medically necessary,” which is 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
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 Nov 19, 2020