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  • Current: Top surgery for a minor - Hormone provider or surgeon checklist

Top surgery for a minor - Hormone provider or surgeon 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 (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,

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Provider’s Name

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Updated on Nov 19, 2020

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