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
- List any puberty suppression or hormone treatments
- Date started
- That they take the hormones consistently and appropriately
- Hormones have not significantly decreased breast tissue
Comment on any other symptoms you are aware of such as
- Chest dysphoria
- Binding, problems associated with binding
- Long-standing desire for surgery
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)
- Address age-related concerns, indicate the maturity of person
- Indicate if the parents consent to and are supportive of this treatment
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
- That the surgery is performed to treat gender dysphoria
- Indicate if the surgery will help to alleviate the person’s gender dysphoria
- If you have seen surgery help other trans patients under 18, note that
State the qualifications of the provider (bolster your credibility 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 treatment of gender dysphoria
- Relevant professional associations
- Relevant publications
- Relevant trainings given, courses taught
- Consider attaching CV if a specialist
- Note any specific competence in treating adolescents with gender dysphoria.
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